Form PC-836 Peace Corps 50th Anniversary Archive

DRAFT 5-15-08

OMB Control # _ _ _ _ _ _

Expiration Date: __________

Peace Corps 50^th Anniversary Archive

In honor of Peace Corps’ 50^th anniversary, Peace Corps invites you to share a story from your Peace Corps experience. Stories will be collected from Volunteers serving in each generation of the Peace Corps, from the 1960s, 70s, 80s, 90s, and on through to the present.

You can also submit photos related to your Peace Corps service. By sharing a story and photos that reflect your unique experience in the place and time you served, you will help enrich Americans’ understanding of what it means to have been a Peace Corps Volunteer. Many of the stories and photos submitted to the archive will be used to honor and celebrate our legacy of service during Peace Corps’ 50^th anniversary celebration in 2011, and the 50^th Anniversary Archive collection will be maintained as part of the Peace Corps’ permanent archives. Archive materials will be accessible to the public through the Peace Corps website, and will be shared with the National Archives and Records Administration (NARA).

We are currently accepting electronic submission of stories and photos from Returned Peace Corps Volunteers (RPCVs). If you are not an RPCV but would like to submit material to the archive, please contact us at archive@peacecorps.gov.

If you are an RPCV, please read the complete submission guidelines for details on what we are collecting and how to submit your materials.

We recommend you prepare your story and photos before beginning the online submission process. It may take up to 30 minutes to submit materials.

Please review the Peace Corps 50^th Anniversary Archive Project Material Submission Authorization and Agreement before continuing. Contributors must accept the terms of the agreement during the submission process in order to upload items to the archive.

Submission Form:

Contact Information

Name: [Last] [First] [Middle]

Email: [--------@-------.---]

Retype email: [--------@-------.---]

Telephone: [xxx-xxx-xxxx]

City: [ ]

State (if U.S.): [ ]

Country (if not U.S): [ ]

Your name at the time of your Peace Corps service, if different from today:

[Last] [First] [Middle]

About Your Service

Country of Service: [Drop-down list of all PC countries]

Service Dates: [Year] – [Year]

Sector:

(select one)

__ Agriculture

__ Business Development

__ Community Development

__ Education

__ Environment

__ Health

__ HIV/AIDS

__ Information Technology

__ Youth Development

Add another tour of service

About the Archive Project

May a Peace Corps staff member or 50^th anniversary project volunteer contact you if we have questions about your submission?

Yes___ No___

We anticipate great interest in the 50^th anniversary among the domestic and international press, partner universities, RPCV groups, and other organizations such as libraries and museums. May we provide your contact information (e-mail and telephone) to groups interested in contacting you for interviews, exhibits, etc.? Note: Peace Corps does not release contact information to groups for the purpose of fundraising.

Yes___ No___

We are working to establish a permanent home for original, primary source archival materials about the Peace Corps experience [e.g., letters, journals, Volunteer newsletters or cookbooks from your country of service, photos, slides, video or audio recordings taken while in service, artwork or artifacts, etc…].

May we contact you at a future date about contributing your original materials?

Yes___ No___

If yes, please describe the original materials you have:

P

Peace Corps 50^th Anniversary Archive Project

Material Submission

Authorization and Agreement

I, on behalf of myself, heirs and assigns, do represent and agree to the following:

1). I am the lawful copyright or intellectual property right holder of the material submitted under this Authorization and Agreement which permits me to provide this material to the Peace Corps under this Authorization and Agreement.

2). I forever grant the Peace Corps a perpetual, worldwide, royalty-free, non-exclusive license in and right to sub-license the materials submitted, and authorize the Peace Corps to make any use of this material. It is my intention to give the Peace Corps the right to disseminate, reproduce, publish, publicize and make any uses of the materials submitted under this Authorization and Agreement, for any purposes whatsoever, through any forum or media possible. By submitting this material, it is my intention to provide the Peace Corps with the maximum reproduction, dissemination, publication, and all other possible usage rights possible by law.

II understand that the Peace Corps may attribute my submission to me, and I hereby authorize the Peace Corps to make any reference to me in regard to these materials. By submitting material to the Peace Corps under this Authorization and Agreement, I understand and agree that this material will be subject to public disclosure under the Freedom of Information Act, may be made accessible to the public by the Peace Corps, and may be submitted to the National Archives and Records Administration and therefore publicly accessible.

3). I understand that the Peace Corps reserves the right to accept, reject or edit all submissions in whole or in part. Any submission under this Authorization and Agreement, if accepted by the Peace Corps under the terms of this Agreement, may be used, maintained or disposed of in the sole discretion of the Peace Corps. I acknowledge that regardless of whether the submission is accepted or rejected by the Peace Corps, it may not be returned to me.

4). I acknowledge that I will receive no financial compensation from the Peace Corps in consideration of my agreement to this Authorization and Agreement, or in regard to my provision of the above listed submissions.

5). My submission of this Authorization and Agreement and affirmative indication of acceptance of the terms of this Authorization and Agreement, through any physical, electronic, fax, or other means serves as my legally valid signature to this Authorization and Agreement, and has the full force and effect of my original written signature.

I accept the terms of this Authorization and Agreement.

Submit your Story

Contributor Info: [automatically populated from the ‘Contact Information’ and ‘About Your Service’ fields above]

Story Title: ­­­­­­­­­­­_______________________ (do not exceed 80 characters)

ATTACH story as a .pdf or .doc file___________

Submit your Photo(s)

Contributor Info: [automatically populated from the ‘Contact Information’ and ‘About Your Service’ fields above]

Photo Title: ________________ (do not exceed 80 characters)

Photo subject(s): (check all that apply)

__ Host Family

__ Host Community Friends

__ Celebrations/Special Occasion

__ Work

__ Food/Meals

__ Housing

__ Transportation

__ Other___________

PLEASE DESCRIBE ITEM: Please provide as much detail as you can—where and when was it taken, who is in the photo, what is happening in the photo, etc…

[e.g., I took this photo during the first day of school celebration on Sept. 1, 1994, at School #97 in Karaganda, Kazakhstan. The first day of school is a major holiday in Kazakhstan and other countries of the former Soviet Union. The photo shows two primary school girls handing flowers to their new teacher in the school auditorium while parents, students, and teachers look on.]

ATTACH PHOTO :__________

ADD ANOTHER PHOTO

Would you like to update your biographical and contact information with Peace Corps’ Office of Returned Volunteer Services? Yes___ No___

PRIVACY ACT NOTICE: This notice is provided under the Privacy Act of 1974, as amended (5 U.S.C. §552a). The information requested is collected under the authority of the Peace Corps Act, 22 U.S.C. §2501 et seq., for the purpose of gathering material in relation to the Peace Corps’ 50^th Anniversary. The information may also be used for routine uses listed in the System of Records Notice PC-31, Peace Corps 50^th Anniversary Archive, which, upon approval, will be available in our electronic reading room at http://www.peacecorps.gov. Providing the material herein is completely voluntary, however failure to disclose sufficient information may result in submissions not being retained.

Paperwork Reduction Act Burden paragraph per 5 CFR Part 1320(b)(3): This is a voluntary information collection.  The estimated burden for completing this form is 15 minutes.  You are not required to respond to any collection of information unless it displays a currently valid OMB approval number.  Comments on the burden should be sent to: the director of the Peace Corps Office of Communications, 1111 20th Street, NW, 2nd Floor, Washington, D.C. 20526 and to the Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C. 20503.

PC-836 (06/2008)Page 0