| I.
Applicant Profile |
| Your
Name: |
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| Email: |
|
| Date
of Birth: |
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| Current
Address: |
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| Permanent
Address: |
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| Telephone
# Current: |
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| Permanent
Telephone #: |
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| Status: |
US Citizen |
|
Permanent Resident |
|
II.
Education (Complete if applicable) |
| Name
of College |
|
| Academic
Major |
|
| Year
in School |
|
| Expected
Graduation Date |
|
|
Are
you in good Academic Standing (GPA
2.0 or above)?
|
Yes
|
|
No |
|
III.
Applicant Job Position (Part-time,
full-year, 900 hours, 20 hours/week)
(Living
Allowance: $5,170.00 Education
Award: $2,362.00) |
| |
|
IV.
Community Involvement, Job History,
Other Activities |
|
Describe
any activities such as volunteer or
community service, past employment,
and other forms of involvement that
are relevant in the text field
below. |
|
|
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V.
Legal |
| Existence
of a criminal
conviction/adjudication may or may
not, depending on the circumstances,
disqualify you from consideration.
However, misrepresentation of that
record - lying or not telling
the truth - will disqualify you.
Answer the following questions
fully. Background/security checks
and fingerprinting will be
performed. |
|
1.
Have you ever been convicted, or
adjudicated as a juvenile offender,
of any criminal offense by a
civilian or military court? Do not
include minor traffic violations. |
Yes |
|
No |
|
2.
Are you now under charges for any
offenses or are any civil suits or
judgments pending against you? (Do
not include charges for minor
traffic offenses) |
Yes |
|
No |
|
3.
If yes, to #2 please complete the
following:
|
Date |
|
Place |
|
Charge |
|
Action Taken |
| Are
you now on probation or parole? |
|
Yes |
|
No |
| Provide
the name, address, and phone number
of the court, probation officer or
parole officer who we can contact to
verify the above information. |
|
Name |
|
Title |
|
Phone Number |
|
Address |
|
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VI.
Personal Statement |
|
Please
answer the following questions.
Limit your responses to a paragraph
for each question.
|
|
1.
What do you hope to give to and
learn from the community you serve
as an AmeriCorps member? |
|
|
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2.
Please describe something you did
for others that demonstrates
leadership. |
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3.
How will you balance your SLFH
AmeriCorps responsibilities with
your other commitments next year? |
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4.
What are your career plans? How are
they related to SLFH? |
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5.
Describe your commitment to the
program and its philosophy of public
service. |
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VI.
References: Provide two letters of
reference from previous employers,
professors, or anyone who can attest
to your ability to fill this
position (family members are
exempted). Postal mail and fax
information is listed below. |
| |
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VII.
By submitting this application, you
are certifying the following:
I
certify that all of the statements
in this application are true,
correct and complete, to the best of
my knowledge, and are made in good
faith. I understand that
misinformation or omission of
information could result in
disqualification and/or termination
as an AmeriCorps member. I also
understand that the information
provided herein may be used to
process my application for
acceptance into AmeriCorps and for
other general routine purposes by
local programs and/or the
Corporation for National Service,
and it will not be disclosed outside
of these entities without written
prior permission. |
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