Form PC-2119 Peace Corps Response Application

Peace Corps Response Application Current OMB Control Number: 0420-0547

Current Expiration Date: ##/##/####

Peace Corps Response Overview Thank you for your interest in applying to Peace Corps Response. Please review the following information before proceeding with this application.

The Peace Corps mission is to promote world peace and friendship through the following:

• Helping people of interested countries in meeting their need for trained men and women
• Helping promote a better understanding of Americans on the part of peoples served
• Helping promote a better understanding of other peoples on the part of Americans

Peace Corps Response assignments aim to accomplish tangible results and address the development needs of the host country in a short period of time, while offering qualified Americans the opportunity to obtain considerable career experience. Assignments range from three months to one year in length.

Volunteers provide targeted assistance in diverse assignments covering a range of projects. Assignments are both challenging and rewarding, requiring a full commitment to serve others. Peace Corps Response Volunteers should have experience in culturally diverse environments as well as the requisite technical expertise and language skills specified in the position description.

Eligibility Requirements

Are you a U.S. citizen (by birth or naturalization)?

• Yes

• No

Naturalization is the manner by which someone who was not born in the United States voluntarily becomes a U.S. citizen. Residency is not a qualifier for eligibility.

If you are a naturalized U.S. citizen, please note that some countries prohibit Volunteers with dual citizenship from utilizing their U.S. passports. However, to ensure Volunteers’ safety and security, the Peace Corps requires all Volunteers to utilize their U.S. passport during service. Before applying to a country in which you have dual citizenship (including nationality bestowed by place of birth), please carefully research any restrictions that may preclude you from service in that country.

Do you expect to become a naturalized citizen within three months of the application deadline?¹

• Yes

• No²

If in the process of becoming a naturalized citizen, please provide your estimated date of naturalization. (m/d/yyyy) ³

Will you be at least 18 years of age prior to the anticipated start date of service?

• Yes

• No

If no:

Thank you for your interest in serving with Peace Corps Response. The information you entered indicates you do not meet eligibility requirements at this time. You must be a U.S. citizen and at least 18 years old to serve.

If you are under 18, please continue your spirit of service, and we encourage you to consider the two-year Peace Corps program or Peace Corps Response again when you are older. For more information regarding eligibility requirements for Peace Corps Response service, please consult the FAQs on our website.

Additional Eligibility Requirements

In addition to being a U.S. citizen and at least 18 years old, Peace Corps Response Volunteers must have applicable experience.

Are you at least one of the following?

• A returned Peace Corps Volunteer

• A professional with significant professional experience

• A doctor or nurse applying to the Global Health Service Partnership (GHSP)

If no:

Thank you for your interest in serving with Peace Corps Response. The information you entered indicates you do not meet our eligibility requirements at this time.

We encourage you to consider applying to the two-year Peace Corps program or consider Peace Corps Response again in the future.

General Questions

How did you learn about Peace Corps Response?

Select One

Email

Facebook

LinkedIn

Conference or Career Event

Peace Corps Website

Peace Corps Staff

Returned or Current Volunteer

Friends or Family

Close of Service Conference

Print Advertisement

Other

If other, indicate here:

Contact Information

Please make sure this page contains your most up-to-date information so Peace Corps Response staff can contact you.

You must provide your full name as it appears on a legal document (e.g., passport, driver’s license, birth certificate, etc.).

Title (dropdown list Mr./Mrs./Miss/Ms./Dr., etc.)

First name (your legal/given name)

Middle name (no initials)

Last name

Suffix (Jr., Sr., etc.)

Nickname (optional)

Primary phone

Secondary phone

Permanent email address

The Peace Corps asks for your Social Security number because the Peace Corps Act, 22 U.S.C. 2519, requires us to do a background check on all Volunteers. The Peace Corps will also use it to ensure our records are accurate for tax and other financial accounting purposes.

Social Security number, including dashes (xxx-xx-xxxx)

Please re-enter your Social Security number, including dashes (xxx-xx-xxxx)

Sex (male/female)

Date of birth (month/day/year)

Current Address

Please ensure that you can collect mail in a timely manner from this address, as important mail and time-sensitive forms will be sent to this address.

Address line 1

Address line 2

Country

City

State/Region/Province

ZIP/Postal code

+4 (of ZIP code)

Upload Your Resume

Please upload your resume below. Your resume should be tailored to reflect only relevant experience for this assignment, as well as experience depicting your flexibility, adaptability, language ability, and cross-cultural skills. In most instances, your resume should not exceed 2-3 pages. By uploading your resume, you agree to permit the Peace Corps to share the information in it with host country agencies and counterparts, other Volunteers, and others the Peace Corps deems necessary or appropriate in connection with your application or possible future Peace Corps service.

Resume/CV

Choose one of the methods below to submit your resume /CV.

Use a resume /CV from my profile
Upload my resume /CV from my computer

Education

What is the highest level of education you have achieved, or will have achieved prior to service? For example, if you are currently a second year master’s student and will have completed your degree prior to beginning your Peace Corps Response assignment, list the degree that you will receive as the highest level of education achieved.

Please provide the information below for all academic institutions you have attended or will graduate from prior to starting your service.

School name:

If school not listed, provide name here:

Type of degree, diploma, or certificate (select one):

Date degree received or expected (mm/yyyy):

Major:

Employment History

Please review the completed fields to ensure the information is accurate. Prior to moving on to the next page of the application, you must identify your “most recent” job.

Position or Job Title:

Organization Name:

Start year:

End year:

Most Recent:

Peace Corps Service History

Have you previously served with the Peace Corps or Peace Corps Response?

If yes:

What is your most recent Peace Corps/Peace Corps Response country of service?

When did you serve there? (MM/YYYY to MM/YYYY)

If you have additional Peace Corps/Peace Corps Response service, please list the countries and dates below.

When did you serve there? (MM/YYYY to MM/YYYY)

Relevant Experience and Skills

This section may auto-populate based upon answers that you have submitted with a previous application. Please verify that your answers address the qualifications for the position for which you are applying.

In one paragraph, please describe how your experience and skills meet the mandatory qualifications listed for this specific position. (2,000 character limit)

Language Skills

Please list any language experience you have, beginning with the language(s) that are most relevant for the position for which you are applying. Additionally, please indicate the level of proficiency for each language selected. If you do not see the language(s) you speak in the list provided, please select the “other” option at the bottom of the list, write in the language, and indicate your level of proficiency.

Language 1

Skill Level (Novice, Intermediate, Advanced, Superior)

Language 2

Skill Level (Novice, Intermediate, Advanced, Superior)

Language 3

Skill Level (Novice, Intermediate, Advanced, Superior)

Couples

The Peace Corps makes efforts to place married couples and domestic partners who wish to serve together. Please be aware that the opportunities to place couples are more limited than those for individual candidates. In order to serve together, both spouses/domestic partners must apply at the same time and qualify for assignments in the same country.

Are you married or in a domestic partnership, or planning to be married or in a domestic partnership at the time you begin your service?

• Yes

• No

For additional information on serving as a couple, visit peacecorps.gov/legalinfo.

Spouse/Domestic Partnership⁴

First name of spouse/domestic partner

Middle name of spouse/domestic partner:

Last name of spouse/domestic partner:

Are you planning to serve with your spouse or domestic partner?

• Yes, I am planning to serve with my spouse

• Yes, I am planning to serve with my domestic partner

• No

Declaration of Domestic Partnership⁵

Please read and confirm the statements below to support your indication that you plan to serve with your domestic partner.

My partner and I:

1. are each other’s domestic partner and intend to remain committed to one another indefinitely,

2. share responsibility for a significant measure of each other’s common welfare and financial obligations,

3. are not married to, joined in civil union with, or domestic partners with anyone else,

4. are not related in a way that would prohibit legal marriage in the state in which we reside,

5. agree to notify the Peace Corps of any dissolution of the domestic partnership not later than 15 days after the date of dissolution of the domestic partnership,

6. understand that falsification of information within this declaration may constitute a criminal violation under 18 U.S.C. 1001 and may lead to disciplinary action, and ⁶

• have a common residence, and intend to continue the arrangement or

• would have a common residence, but are prevented from having one due to the following circumstances (please explain below).⁷

Explanation if you do not currently share a common residence:

I declare under penalty of perjury that the preceding is true and correct.

• Yes

Signature

Declaration date

For additional information on serving as a couple and the required legal documentation, visit peacecorps.gov/legalinfo.

Dependents

Serving as a Peace Corps Response Volunteer with dependents at home or elsewhere is often a challenge. For additional information on dependents, visit peacecorps.gov/legalinfo.

Are any persons partially or totally dependent upon you for support, whether or not they are living with you?

• Yes

• No

Dependent Information⁸

Name of dependent

Dependent’s date of birth (m/d/yyyy)

Do you have an additional dependent?⁹

• Yes

• No

Military Status

Are you a veteran or currently serving in the military?

• Yes

• No

Do you have any military, reserve, or National Guard obligations?¹⁰

• Yes

• No

For more information regarding military obligations, visit peacecorps.gov/legalinfo. 

Legal History

The existence of an arrest or conviction record will not automatically exclude you from consideration for Peace Corps service. When evaluating an arrest or conviction, the Peace Corps considers the nature of the offense, how long ago the offense occurred, whether you were acquitted of the offense, and other relevant facts or indications of rehabilitation. If you are ultimately rejected for a Peace Corps Volunteer position because of an arrest or conviction, you can request a review of the decision and/or reapply at a later date. 

For more information go to peacecorps.gov/legalinfo. 

It is your responsibility to inform the Peace Corps promptly throughout the application process, up through the start of service, of all new arrests, charges, citations, misdemeanors, and felonies (including ALL drug- or alcohol-related legal incidents) and any other changes to the information provided below, including the disposition of existing offenses. Do not include minor traffic violations, citations, or parking tickets.

Are you currently involved in any court proceedings (civil or criminal) that will require your participation (as a plaintiff, defendant, or witness) during the time you would be serving as a Peace Corps Volunteer?

• Yes

• No

All Peace Corps invitees must undergo a background check that will disclose all arrests and convictions, regardless of whether the arrest or conviction has been expunged from your record. If you fail to disclose information about your legal history, including expunged cases, the Peace Corps may revoke your invitation to serve or disqualify you from Peace Corps service. Have you ever been cited for, arrested, charged with, or convicted of any offense? (Exclude minor traffic violations, citations, and parking tickets.)

• Yes

• No

Legal Offense¹¹

Please upload your court documents as a supplement to the application in the application portal, which can be accessed after submitting an application.

Type of offense (e.g., DUI, possession of marijuana, petty theft)

Date of incident (m/d/yyyy)

Please upload your court documents as a supplement to the application in the applicant portal, which can be accessed after submitting an application.

Location of incident

Give a complete narrative explanation of the circumstances surrounding the incident. The narrative should comprehensively explain what happened leading up to the incident, what happened during the incident, and how the incident was resolved.

Was there a final court judgment?

• Yes

• No

Final Court Judgment¹²

List all penalties including sentence, probation, community service, fines, or other penalties imposed:

Judgment date (m/d/yyyy)

Current status or disposition¹³:

Are you currently on probation of any kind?

• Yes

• No

Probation¹⁴

What are the current requirements of your probation?

Please state when and how your probation obligations will be met:

Additional Incidents

Do you have any other legal incidents to report?¹⁵

• Yes

• No

Drug and Alcohol Policy

During Application

An applicant with any drug-related conviction or with a conviction for public intoxication, driving under the influence (DUI), or driving while intoxicated (DWI), with a conviction for reckless driving after having been initially charged with DUI or DWI, or who has a similar alcohol-related conviction, will not have his or her application for Peace Corps service considered until 12 months has passed from the date of the incident. The Peace Corps may deem an applicant unsuitable for Peace Corps service due to drug abuse, problem drinking, and/or alcohol abuse.

An applicant who, at any time on or prior to the day of departure for Peace Corps service, is arrested for any drug offense or for public intoxication, DUI, DWI, or any similar alcohol-related offense will have any pending application or invitation for Peace Corps service withdrawn. If the charges are dismissed, an applicant whose application or invitation for Peace Corps service was terminated may immediately reapply. If the applicant is convicted of the offense, he or she may reapply after 12 months from the date of the incident.

Drug and Alcohol Use by Volunteers Overseas

A Volunteer found to be involved with drugs in a manner not authorized for medical purposes, in any way in any country, will be administratively separated immediately. The Peace Corps enforces this strict policy not only because the cultivation, manufacturing, and trafficking, and use of drugs, including marijuana, is illegal in most countries, but also because drug involvement by Volunteers in any country could seriously jeopardize an entire Peace Corps country program, as well as the safety and health of other Volunteers.

The Peace Corps leaves decisions regarding the use of alcohol to the discretion of the individual Volunteer. The Peace Corps recognizes, however, that excessive use of alcohol may compromise Volunteer safety and security, lead to behavior that discredits the Peace Corps or the individual Volunteer, or affect the Volunteer’s performance and success in an assignment. Examples of such behavior include, but are not limited to: public intoxication, drinking while at a work site, failure to appear for work or training due to intoxication or hangovers, and verbal or physical aggressiveness while under the influence of alcohol. Such inappropriate or unsafe behavior or inability to perform adequately in the assignment may be grounds for disciplinary action, including administrative separation.

• I confirm that I have read the Peace Corps Drug and Alcohol Policy.

Have you been cited for, arrested, charged with, or convicted of any drug or alcohol related offense in the last five years?

• Yes

• No

Intelligence Background The Peace Corps has a longstanding policy excluding individuals who have engaged in intelligence activity or related work or who have been employed by or connected with an intelligence agency from Peace Corps Volunteer service, either for a specific period of time or permanently, depending on the agency. For more information, including definitions of “intelligence activity” and “intelligence agency,” visit peacecorps.gov/legalinfo.

If you are a current or former employee of the Central Intelligence Agency (CIA), you are permanently ineligible for Peace Corps Volunteer service. If you are currently or were formerly employed by another intelligence agency, you are ineligible for Peace Corps Volunteer service for at least 10 years from the end date of such employment. In addition, you may be disqualified for service because your background or history discloses a substantial connection with an intelligence activity or related work other than through employment. Even family relationships to an employee of an intelligence agency may be considered a disqualifying connection. The duration of the disqualification will ordinarily not exceed 10 years and will depend on the nature of your involvement in or relationship to intelligence activities or agencies.

You should also be aware that, if you serve as a Peace Corps Volunteer, you may be ineligible for employment with U.S. government intelligence agencies for a specified period following your service as a Volunteer.

If you or an immediate family member works for or has worked for the CIA or the National Security Agency, go to peacecorps.gov/legalinfo for further instructions before answering the question below.

In all other cases, if you indicate that either you or an immediate family member has been employed by or connected with an intelligence agency, or engaged in intelligence activity or related work, a Peace Corps representative will contact you after your application is submitted to obtain additional information and determine your eligibility for Peace Corps Volunteer service.

Have you or an immediate family member ever been employed by or connected with an intelligence agency, or engaged in intelligence activity or related work?

• Yes¹⁶

• No

Request for Racial and Ethnic Data (Optional)

This information is voluntary. Your response will not affect consideration of your application. By providing this information, you will assist in assuring that the Peace Corps is administered in a nondiscriminatory manner and reflects the diversity of the United States.

Ethnicity

Are You Hispanic or Latino? (a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race)

• Yes

• No

• I prefer not to respond

Race

Please check one or more of the classifications below.

• White. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

• American Indian or Alaska Native. A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

• Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

• Black or African American. A person having origins in any of the black racial groups of Africa.

• Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

• I prefer not to respond.

Privacy Act Statement

The Peace Corps, a U.S. government agency, is required by the Privacy Act of 1974 (5 U.S.C. 552a) to advise you of the following information regarding this application. The Privacy Act addresses the federal government’s use of certain personal information in agency files. 

A. This application is authorized by the Peace Corps Act (22 U.S.C. 2501 et seq.) as amended. 

B. The information you provide will be used to evaluate your suitability and qualifications to serve as a Peace Corps Volunteer. 

C. This information may be used for the routine uses described in the Privacy Act, 5 U.S.C. 552a, and the Peace Corps' published Routine Uses, summarized in Peace Corps' System of Records. 

D. The completion of this application is voluntary. However, failure to complete the application will result in the Peace Corps’ inability to assess your qualifications and may preclude your consideration for the Peace Corps. 

E. The Peace Corps asks for your Social Security number because the Peace Corps Act, 22 U.S.C. 2519, requires us to do a background check on all Volunteers. The Peace Corps will also use it to ensure our records are accurate for tax and other financial and accounting purposes.

Paperwork Reduction Act Burden Statement

Public reporting burden for this information collection is estimated to average one hour. This includes the time for reviewing instructions and completing the information. This is a voluntary information collection. An agency may not conduct or sponsor, and persons are 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: the FOIA Officer, Peace Corps, 1111 20th Street, NW, Second Floor, Washington, DC 20526. 

PLEASE NOTE: The Peace Corps does not discriminate based on race, color, religion, sex, national origin, age (over 40), disability, sexual orientation, gender identity, gender expression, marital status, parental status, political affiliation, union membership, genetic information, or history of participation in the EEO process, any grievance procedure, or any authorized complaint procedure. Anyone who feels he or she has been discriminated against should contact the Office of Civil Rights and Diversity, 202.692.2139, ocrd@peacecorps.gov, 1111 20th Street, NW, Washington, DC 20526. 

Certification

I certify that all of the statements made on all pages of this application, including attachments, are true, correct, and complete to the best of my knowledge and are made in good faith. I understand that any misleading, inaccurate, or incomplete information may be cause for disqualification or termination of Peace Corps service. Any intended omission or intentionally false statement may constitute a violation of federal and state laws and subject you to severe civil and criminal penalties, including fines and/or imprisonment pursuant to 18 U.S.C. 1001. 

I also understand it is my responsibility throughout the application process, up through the start of service, to inform the Peace Corps promptly of any changes to the information provided here. Failure to do so may be cause for disqualification or termination of Peace Corps service.

For Peace Corps Response applicants applying to Global Health Service Partnership assignments, I authorize the Peace Corps to disclose the information in my application to Seed Global Health for the purposes of evaluating my qualifications.

Signature

Date: MON-DD-YYYY

Application Review

Please verify that the information in your application is correct by using the “Preview” link below. To make edits to the application itself, please use the “Previous” button at the bottom of this page (do not press the back button). Once your application is final, click the “Submit” button to complete the application.

Failure to provide correct information in the following fields can significantly delay your application process:

• Name as it appears on a legal document (passport, driver's license, birth certificate, etc.)

• Social Security number

• Date of birth

• Sex

• Email address

• Current address

Thank you for your interest in serving as a Peace Corps Response Volunteer. We look forward to reviewing your application.

We invite you to continue searching for positions that match your interests as you may submit multiple Peace Corps Response applications.

In addition, connect with us on Facebook and sign-up for our monthly newsletter for the most up-to-date vacancy announcements, online information sessions, and exciting stories of Volunteer service!

1 This question appears if applicant responds “No” to preceding question.

2 A “No” response redirects the applicant out of the application: Thank you for your interest in the Peace Corps. The information you entered suggests you may not meet our eligibility requirements at this time.

3 This question appears if applicant responds “Yes” to preceding question.

4 This section appears if applicant responds “Yes” to preceding question.

5 This section appears if applicant responds “Yes, I am planning to serve with my domestic partner.”

6 Applicant selects one to describe living arrangement.

7 Text area provided for explanation.

8 This section appears if applicant answers “Yes” to preceding question.

9 Applicant can list additional dependents.

10 This question appears if applicant responds “Yes” to preceding question.

11 Section appears if applicant answers “Yes” to preceding question.

12 Section appears if applicant answers “Yes” to preceding question.

13 Applicant chooses from the following: guilty (including expunged/sealed), dismissed, diversion program, not guilty, deferred judgments/suspended sentence, or other.

14 Section appears if applicant answers “Yes” to preceding question.

15 Applicants can report up to five legal incidents on the Peace Corps application. After five legal incidents, the following instructions and question appear: “If there are additional legal incidents in your history, please check the box below. The Legal Eligibility Specialist may contact you for further details.”

16 If applicant selects “Yes” a Peace Corps staff member will contact the applicant for details.

PC-2119 13