PC-1835b Staff Story Submission

OMB No. 0420-xxxx
Expiration Date: xx/xx/20xx

Staff Story Submission
Thank you for your interest in contributing to the Peace Corps Digital Library. Your contribution will
help ensure that the Peace Corps' rich legacy of service is maintained for future generations.
Are you contributing a story that reflects your time as a Peace Corps Volunteer? Please submit it to
our Volunteer collection.
» Volunteer Story Submission

Story Submission Guidelines
Please note that you may only submit one story. In order to be published in the digital library, your
submission must:

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Be 1,500 words or less;
Be sensitive to the privacy concerns of individuals, including host country nationals;
Not malign the Peace Corps, or any other group or individual;
Not include inflammatory, rude or offensive language or content;
Not include links to or URLs for Internet sites;
Not be used to promote products or services;
Not include any personal identifying information such as Social Security numbers, phone numbers,
email addresses or street addresses
Peace Corps reserves the right to edit or reject submissions to the digital library. For additional
information and tips on telling your story read our Story Ideas and Suggestions.
Note: fields with an asterisk (*) are required.

Add Story
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* Story Title
(80 character limit)

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* Upload Story
Please submit your story in Microsoft Word (.doc, .docx), rich text (.rtf) or plain text (.txt) format.
DO NOT include spaces or special characters (&, #, !, ?) in the filename.

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My submission adheres to the story submission guidelines outlined above Please verify you read
the story submission guidelines
Note: The information you enter below will automatically populate on any subsequent submissions you
make today.
Burden Statement:
Public reporting burden for this collection of information is estimated to average 15 minutes per response. This estimate includes the time for
reviewing instructions and completing the collection of information. An agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate
or any other aspect of this collection of information, including suggestions for reducing this burden, to: FOIA Officer, Peace Corps, 1111 20th
Street, NW, Washington, DC 20526 ATTN: PRA (0420-####). Do not return the completed form to this address.
PC-1835b (rev. 1/2013)

Contact Information
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* First Name

Middle Name

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* Last Name

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* City

* State

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* Country

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* Email

* Re-type Email

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* Telephone

Was your name different at the time of your Peace Corps employment?

About Your Employment
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* Country
Country of Employment

Yes

No

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* Employment Dates
Begin

End

Did you work for Peace Corps for an additional tour?

Yes

No

About the Digital Library Project
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May a Peace Corps staff member contact you if we have questions about your submission?
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Yes
No Please indicate if a Peace Corps staff member may contact you about your
submission
We anticipate great interest in the 50th 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 (email 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.]
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Yes
No Please indicate if we may provide your contact information to groups interested in
contacting you for 50th Anniversary activitiesn
We are working to establish a permanent home for original, primary source archival materials about
the Peace Corps experience [Ex. 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?
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Yes
No Please indicate if we may contact you at a future date about contributing your
original materials
If yes, please describe the original materials you have:

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characters remaining

Authorization and Agreement
full description below

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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 sublicense 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.
I 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.

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I accept the terms of the Peace Corps Material Submission Authorization and Agreement. Please
verify you read the authorization agreement
Submit

If you are experiencing difficulties submitting your materials, please email digital@peacecorps.gov to
notify the system administrator.