3 AmeriCorps Member Application 12.7.12

AMERICORPS MEMBER APPLICATION

Your World. Your Chance
To Make It Better.

APPLY
TODAY!
AmeriCorps.gov

Thousands of Opportunities Await.

Apply Today!
To learn more about AmeriCorps
and each of the programs, visit
AmeriCorps.gov. Or call the
AmeriCorps hotline at 1-800-942-2677
(TTY 1-800-833-3722).

Print out and use this application OR go to the My AmeriCorps Portal
and apply online https://my.americorps.gov

PLEASE READ THIS INFORMATION BEFORE
COMPLETING THE APPLICATION
• This application may be used to apply for AmeriCorps State, National, NCCC and VISTA programs.
However, if you are applying to an AmeriCorps State or AmeriCorps National program, you should first
check with the program to see if it requires additional or alternate forms. To determine specific application requirements, visit the AmeriCorps website at AmeriCorps.gov or call 1-800-942-2677.
• If you're applying to more than one AmeriCorps program, complete the entire application except for
question 11 and the final "Certification" Section. Make one copy of the application for each program.
Then, answer question 11 and sign each copy separately before mailing.
• You may use additional sheets of paper to provide more detailed information that will not fit on this
application form. Enclose everything in the final application packet that you submit.
• Two reference forms are enclosed in this packet. They are an important part of your application and
must be submitted with your application. Your application cannot be considered without references. If
you are applying to multiple programs and using the same person as a reference, please remind them
to make multiple copies after completing the reference form.
• Make a copy of your application for your personal records before you send it in.
• Send your application to the right place. Please refer to the back cover for instructions.
• This publication is available upon request in alternative formats for people with disabilities.
Call 1-800-942-2677; TTY: 1-800-833-3722.
Public reporting burden for this collection of information is estimated to average 1.25 hours per submission, including
reviewing instructions, gathering and maintaining the data needed, and completing the form. Comments on the burden or
content of this instrument may be sent to the Corporation for National and Community Service, 1201 New York Avenue,
NW, Washington, DC 20525. The Corporation informs people who may respond to this collection of information that they
are not required to respond to the collection of information unless the OMB control number and expiration date displayed
on page 1 are current and valid. (See 5 C.F.R. 1320.5(b)(2)(i).)
OMB# 3045-0054 Expires 04/30/2012

AMERICORPS APPLICATION
PERSONAL PROFILE
1.

NAME:________________________________________________________________________
LAST

FIRST

MIDDLE

Preferred Name ______________________________________________

2.

AmeriCorps members must be a United States citizen, U.S. national or lawful permanent resident.
Are you a United States citizen, national, or lawful permanent resident alien?
■ Yes ■ No
If you are a lawful permanent resident alien and you received your card after January 1987, what is
your registration number and card expiration date? ____________________________________

*Citizens of the US include persons born in Puerto Rico, Guam, the US Virgin Islands, and the Northern Mariana Islands. Nationals of the US
include persons born in America Samoa, inlcuding Swains Island. **Generally, you are a Lawful Permanent Resident Alien of the US if you are
a US permanent resident with (i) a Permanent Resident Card, INS Form I-551; (ii) an Alien Registration Receipt Card, INS Form I-551, (iii) a
passport indicating that the INS has approved it as temporary evidence of lawful admission for permanent residence; or (iv) a Departure
Record (INS Form I-94) indicating that the INS has approved it as temporary evidence of lawful admission for permanent residence. NOTE: A
student visa does not confer eligibility to enroll in an AmeriCorps program.”

3.

FINAL FOUR NUMBERS OF SOCIAL SECURITY NUMBER:________________________________

You will provide your full social security number later in the process.

4.

DATE OF BIRTH: ________________________________________________________________
MONTH/DAY/YEAR

5.

PLACE OF BIRTH: ______________________________________________________________
CITY/STATE/COUNTRY

■ Male

■ Female

6.

GENDER:

7.

Earliest date you are available to begin service: ________________________________________
MONTH/DAY/YEAR

Latest date available ___________________________________
8.

CURRENT ADDRESS: All information will be sent to this address unless you notify us of a change.
______________________________________________________________________________
NUMBER AND STREET (IF POSSIBLE, INCLUDE A NUMBER AND STREET ADDRESS WHEN USING A P.O. BOX)

______________________________________________________________________________
CITY

Preferred Phone (_____)__________________

STATE

Other Phone (_____)_______________________

E-Mail ________________________________
Preferred method of communication ■ phone

1

ZIP CODE

■ email

AMERICORPS APPLICATION
9.

Are you moving within the next six months? ■ Yes ■ No If yes, when*? _________________
*Please notify us of new address at time of move.

MONTH/DAY/YEAR

10. PERMANENT ADDRESS (if different than above): Please give the name and address of a person

____________________

through

whom you can always be reached:

Name: _______________________________________ Relationship: ______________________
FIRST

LAST

________________________________________________________________________________________________________
NUMBER AND STREET (IF POSSIBLE, INCLUDE A NUMBER AND STREET ADDRESS WHEN USING A P.O. BOX)
________________________________________________________________________________________________________
CITY
STATE
ZIP CODE

Home Phone (_____)__________________

Work Phone (_____)_______________________

Cell Phone (_____)____________________

E-Mail __________________________________

2

AMERICORPS APPLICATION
11. Which AmeriCorps program are you applying to? Check only one. If you are applying to more than one AmeriCorps
program, fill this in after you copy your application. Enter the program information on each application.

■ AmeriCorps NCCC (National Civilian Community Corps)
Members ages 18 to 24 serve in a 10-month team-based residential program to complete a variety
of service projects in the areas of education, disaster services, the environment, and other unmet
needs. Members often travel to projects throughout their region.
■ Fall Class (September/October start dates)

■ Winter Class (January start dates)

■ AmeriCorps VISTA (Volunteers in Service to America)
Members who are at least 18 years old provide indirect service through private organizations and
public nonprofit agencies, addressing issues related to poverty—such as financial security,
homelssness and helping, disadvantaged youth, community development, and employment—by
developing and mobilizing resources that create long-term sustainable benefits at a community level.
Program Name _____________________________________________________________________
Program Address ___________________________________________________________________
■ AmeriCorps State and National
Members who are over the age of 17 serve either in teams or individually through national and
community-based private and public organizations. Members help solve community problems
through direct and indirect service in the areas of education, public safety, the environment, and
other human needs, such as health and housing.
Program Name _____________________________________________________________________
Program Address ___________________________________________________________________

EDUCATION
12. Check the highest level of education that you will have completed by the time you are planning to serve
in AmeriCorps. (Check only one.)
■
■
■
■

Less than high school
High school diploma
Technical school/Apprenticeship
GED

■
■
■
■

Associate's degree (AA) ■ Graduate degree
Some college
■ Some Graduate
College Graduate
Professional Degree (medical, law)

13. List all schools after high school that you have attended, including trade or technical schools, military
training and employment training programs.
Name of School
(List most recent first)

Location
of School
(City/State)

Dates Attended
From
To
Mo./Yr.
Mo./Yr.

Major
or Area
of Study

Type of
Degree or
Certificate

Date
Received or
Expected

A. _______________________________________________________________________________________________________________
B. _______________________________________________________________________________________________________________
C. _______________________________________________________________________________________________________________

3

D. _______________________________________________________________________________________________________________

AMERICORPS APPLICATION
COMMUNITY SERVICE (Previous service is not always a requirement.)
14. Please provide a description of why you volunteer. Describe how you have reached out to help others
and/or how you have been involved in your own community. Please explain why you serve or get
involved and what you have learned through your community service activities. Think in broad terms.
Your involvement could include serving in the neighborhood; school; faith, social, or professional
groups. (200 characters maximum)
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Please list the organizations with which you have been involved to perform community service.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
A. DATES OF INVOLVEMENT: From: ___________ To: ____________ Hours per mo.: ____________
MONTH/YEAR

MONTH/YEAR

Organization Name: __________________ Location: _________________ Phone: ____________
Description of Involvement: ________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
B. DATES OF INVOLVEMENT: From: ___________ To: ____________ Hours per mo.: ____________
MONTH/YEAR

MONTH/YEAR

Organization Name: __________________ Location: _________________ Phone: ____________
Description of Involvement: ________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

4

AMERICORPS APPLICATION
MOTIVATIONAL STATEMENT
15. We would like to understand more about you and your reasons for applying to AmeriCorps. Please
share with us why you would like to serve with the AmeriCorps program. If you need additional space,
attach a separate piece of paper and limit your total response to 500 words.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

EMPLOYMENT
16. Beginning with the most current or most recent position, list and briefly describe the last four positions
you have held or your last ten years of employment. Begin with the current or most recent and go back
ten years. Include self-employment, internships/fellowships, home management, and full- or part-time
paid or unpaid work experience. (You may attach a resume instead if it addresses the information
requested below.)

NAME AND ADDRESS OF EMPLOYER
A. Organization, City/State:
_____________________________
_____________________________

DATES
From: _____/_____
MO./YR.

To: _____/_____

JOB TITLE AND DUTIES
Title: ________________________
Duties: ______________________
____________________________

MO./YR.

Supervisor: Phone and email
_____________________________

Hrs./week: _______

____________________________

B. Organization, City/State:

From: _____/_____

Title: ________________________

_____________________________
_____________________________
Supervisor: Phone and email
_____________________________

5

Reason for leaving: ____________

MO./YR.

To: _____/_____
MO./YR.

Hrs./week: _______

Duties: ______________________
____________________________
Reason for leaving: ____________
____________________________

AMERICORPS APPLICATION
NAME AND ADDRESS OF EMPLOYER
C. Organization, City/State:

DATES
From: _____/_____
MO./YR.

_____________________________
_____________________________

To: _____/_____

JOB TITLE AND DUTIES
Title: ________________________
Duties: ______________________
____________________________

MO./YR.

Supervisor: Phone and email

Reason for leaving: ____________

_____________________________

Hrs./week: _______

____________________________

D. Organization, City/State:

From: _____/_____

Title: ________________________

MO./YR.

_____________________________
_____________________________

To: _____/_____

Duties: ______________________
____________________________

MO./YR.

Supervisor: Phone and email
_____________________________

Reason for leaving: ____________
Hrs./week: _______

____________________________

17. Please explain any gap in employment greater than six months not accounted for by AmeriCorps, Peace
Corps, work, school, or military service. Or, explain why you have no employment history.
____________________________________________________________________________________
_________________________________________________________________________________
SKILLS
AND EXPERIENCE
18. Listed below are skill areas that some programs find useful and may seek in AmeriCorps applicants. Indicate the
skill areas in which you have had training or experience, including volunteer or community service experience,
and indicate how you gained those skills.

✓

EXAMPLE: ■ Public Speaking – Club President
■
■
■
■
■
■
■
■
■
■
■
■
■
■
■

Architectural Planning ______________________
Business/Entrepreneur ______________________
Communications __________________________
Community Organization ____________________
Computers/Technology ______________________
Conflict Resolution__________________________
Counseling________________________________
Education ________________________________
Fine Arts/Crafts ____________________________
First Aid __________________________________
Fundraising/Grant Writing ____________________
Law ____________________________________
Leadership________________________________
Medicine ________________________________
Public Health ______________________________

■
■
■
■
■
■
■
■
■
■
■
■
■
■

Public Speaking____________________________
Recruitment ______________________________
Teaching/Tutoring __________________________
Trade/Construction__________________________
Writing/Editing ____________________________
Youth Development ________________________
Other (specify): ____________________________
Environment ______________________________
Non-Profit Management ____________________
Social services ____________________________
Urban Planning ____________________________
Disaster Services __________________________
Veterans__________________________________
Teamwork: ________________________________
6

AMERICORPS APPLICATION
19. What is your primary language? _____________________________
Do you speak another language? ■ Yes ■ No
Language(s): _____________________ Number of years studied or spoken: ___________________
Speaking Ability: ■ Poor
Writing Ability: ■ Poor

■ Fair
■ Fair

■ Good
■ Good

■ Excellent
■ Excellent

19a. List all current certificates along with their expiration dates. Example: EMT-Expires 12/31/2012
Certificate: ___________________________ Expiration Date (mm/dd/yyyy): ________________

20. In the space below or on a separate sheet of paper, provide any additional skills and experience that
may be helpful in evaluating your application, including other languages spoken.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

21. Do you have a valid government issued driver’s license?

■ Yes ■ No

AMERICORPS APPLICATION
CRIMINAL HISTORY
The AmeriCorps application process requires a criminal history check to ensure that community members
with whom we work are protected, particularly children, individuals with disabilities, and individuals over 60
years old.
We are investigating for past sexual offenses and violent crimes, or crimes that would have a direct bearing
on your service. This background check will entail our search of the National Sex Offenders Registry may
include a Statewide criminal history repository check and/or an FBI criminal history check, which will
require you to submit fingerprints.
You will not be permitted to serve or work with children, individuals with disabilities, or individuals over 60
years of age, without supervision until the history check is complete and you are cleared. The review
process is not lengthy, and normally is completed within weeks.
Answer the following questions fully. Existence of a criminal conviction or juvenile adjudication may or may
not, depending on the circumstances, disqualify you from consideration. However, any intentional misrepresentation or omission is grounds for disqualification.

22. Have you ever been convicted as an adult, or adjudicated as a juvenile offender, of at least one
criminal offense by either a civilian or military court? ■ Yes ■ No
Are you currently facing charges for any offense or on probation or parole?
If no, skip to “Certification” below.

■ Yes ■ No

If you answered “yes” to any of the questions above, please provide the following information:
Date: ___________________________ Place: ___________________________________________
MONTH/DAY/YEAR

CITY STATE

Charge: ___________________________________________________________________________
Action Taken: ______________________________________________________________________
Court, Probation, or Parole Officer: ____________________________Phone: (_____ ) ___________
Name: ___________________________________________________________________________
Address: ________________________________________________________________________
NUMBER AND STREET

______________________________________________________________________________
CITY

STATE

ZIP CODE

You may attach any additional information or explanation on a separate sheet.

8

AMERICORPS APPLICATION
CERTIFICATION
If you choose to submit a paper application, your application must be certified with your original signature
in ink. If you are applying to more than one AmeriCorps program, make a copy for each program that
you’re applying to first, and then sign each one.
By signing this application, or by submitting it electronically if applying on-line, I certify that all of the statements made in this application are
true, correct, and complete, to the best of my knowledge, and are made in good faith. Misinformation or omission of information could result in
disqualification or termination as an AmeriCorps member. If I am selected for participation in some AmeriCorps programs, including
AmeriCorps NCCC, I may be required to submit to a physical examination, including drug or alcohol testing. Background and security checks
may also be conducted by some programs.
PUBLIC BURDEN STATEMENT: Public reporting burden for this collection of information is estimated to average 1.5 hours per submission,
including reviewing instructions, gathering and maintaining the data needed, and completing the form. Comments on the burden or content of
this instrument may be sent to the Corporation for National and Community Service, Attn: Amy Borgstrom, 1201 New York Avenue, NW,
Washington, D.C. 20525. The Corporation informs people who may respond to this collection of information that they are not required to
respond to the collection of information unless the OMB control number and expiration date displayed on page 1 are current and valid. (See 5
C.F.R. 1320.5(b)(2)(i).)
PRIVACY ACT NOTICE: The Privacy Act of 1974 (5 U.S.C § 552a) requires that the following notice be provided to you: The authority for collecting information from you in this application is contained in 42 U.S.C 12592 and 12615 of the National and Community Service Act of 1990
as amended, and 42 U.S.C 4953 of the Domestic Volunteer Service Act of 1973 as amended. You are advised that submission of the information is entirely voluntary, but the requested information is required in order for you to participate in AmeriCorps programs. The principal purpose for requesting this personal information is to process your application for acceptance into an AmeriCorps program, and for other general
routine purposes associated with your participation in an AmeriCorps program. These routine purposes may include disclosure of the information to federal, state, or local agencies pursuant to lawfully authorized requests, to present and former employers, references provided by you
in your application, and educational institutions, for the purpose of verifying the information provided by you in your application. The information may be shared with other agencies, such as the Social Security Administration, through computer matching agreements for the purpose of
verifying identity and citizenship status information provided by you in your application. In some programs, the information may also be provided to federal, state, and local law enforcement agencies to determine the existence of any prior criminal convictions. The information may
also be provided to appropriate federal agencies and Department contractors that have a need to know the information for the purpose of
assisting the Department’s efforts to respond to a suspected or confirmed breach of the security or confidentiality or information maintained in
this system of records, and the information disclosed isrelevant and unnecessary for the assistance. The information will not otherwise be
disclosed to entities outside of AmeriCorps and the Corporation for National and Community Service without prior written permission.

____________________________________________________________
SIGNATURE

DATE

Print Name: _______________________________________________________________________________

For Parent or Guardian of Applicants Under 18 Years of Age: I have reviewed this application and I authorize
my son/daughter/legal ward to apply to AmeriCorps.
____________________________________________________________
SIGNATURE

DATE

NAME: _________________________________________________________________________________________________________________
RELATION: ____________________________________________________ PHONE: (______)__________________________________________
ADDRESS:___________________________________________________________________________________________
(IF P.O. BOX, ALSO GIVE NUMBER AND STREET)

CITY

STATE

ZIP CODE

Corporation for National and Community Service programs are available to all without regard
to race, color, national origin, disability, age, gender, sexual orientation, religion, political affiliation, or other
non-merit factors. Anyone believing he or she has been subjected to discrimination on these grounds by
the Corporation for National and Community Service, AmeriCorps, or one of its grantees may contact our
Office of Civil Rights and Inclusiveness at (202) 606-7503 or email at eo@cns.gov.

1

REFERENCE FORM
TO THE APPLICANT:
Please complete the information below and give this form to each of your references. You should select people who
know you well and who are familiar with your personal background, education, employment, and/or professional
skills. You should not ask a family member, peer, classmate, co-worker, or friend to serve as a reference.
Consider asking work supervisors, clergy, teachers, counselors, coaches, or someone else familiar with your motivation and community involvement.
Your reference should complete this form, seal it in an envelope, sign his or her name across the seal on the outside
of the envelope, and return it to you to include with the application you send to AmeriCorps.
Applicant’s Name: ______________________________________________________________________________
LAST

FIRST

MIDDLE

Address:______________________________________________________________________________________
(IF P.O. BOX, ALSO GIVE NUMBER AND STREET)

Home Phone: (_____)__________________

CITY

STATE

ZIP CODE

Work Phone: (_____)____________________

INDICATE THE PROGRAM THAT YOU ARE APPLYING TO (check only one):
■
■

AmeriCorps NCCC
AmeriCorps VISTA
Program name: ____________________________________________________________________
Program address: __________________________________________________________________

■

AmeriCorps State and National:
Program name: ____________________________________________________________________
Program address: __________________________________________________________________

TO THE PERSONAL REFERENCE:
AmeriCorps engages more than 70,000 Americans a year in results-driven service sponsored by thousands of local
and national nonprofits, public agencies, and faith-based and community organizations. AmeriCorps members help
communities meet critical challenges in the areas of education, public safety, the environment, and other human
needs. In return, AmeriCorps members may earn a Segal AmeriCorps Education Award that helps pay for college or
pay back student loans.
The person named above is applying to be an AmeriCorps member. The applicant has indicated that you would be
able to evaluate his or her qualifications and provide us with a candid recommendation.
The success of AmeriCorps largely depends upon an appropriate match between programs and
members. Considerable value is placed on personal references during the application review and selection process.
Your input is greatly appreciated.
Name of Reference: ____________________________________________________________________________
LAST

FIRST

MIDDLE

Position/Title: _________________________________________________________________________________
Organization/Institution: _________________________________________________________________________
Address: _____________________________________________________________________________________
(IF P.O. BOX, ALSO GIVE NUMBER AND STREET)

CITY

STATE

ZIP CODE

Home Phone: (____)______________ Work Phone (____)______________ E-mail: _________________________
10

2
KNOWLEDGE OF THE APPLICANT
How long have you known the applicant? Years:__________________ Months: ____________________
In what capacity have you known the applicant?

■ Job Supervisor/Employer

■ High School Teacher

■ Clergy

■ Volunteer Supervisor

■ College Instructor

■ Coach

■ Other (specify): ____________________________________________________________________________
Please describe the situation in which you know the applicant.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

WORK PERFORMANCE
1.

Please comment on such qualities as the applicant's level of dependability, initiative, and ability to work with
minimal supervision and as a member of a team.

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
2. In your judgment, how competent is this applicant, as demonstrated by work in the community,
in school, on the job, or in a position of responsibility? Please check one.

■
■
■
■
■
11

Outstanding performance
Above average performance
Satisfactory
Below average performance
Unsatisfactory performance

3
RELATIONSHIPS WITH OTHER PEOPLE
3.

AmeriCorps members must serve and communicate with people of varied cultural, economic, educational, racial,
and religious backgrounds. Please comment briefly on the applicant's relationships with others and ability to
work as a member of a team.

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

EMOTIONAL MATURITY
4.

Please comment on the applicant's ability to adapt and work under difficult and changing conditions.

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

ADDITIONAL COMMENTS AND SUPPORTING INFORMATION
5.

If you wish, use additional paper to explain any of your ratings, and anything else about this
applicant that you feel is relevant to serving in AmeriCorps-such as the applicant's desire to serve others,
maturity, work ethic, flexibility, and dependability. Explain any reservations that you have regarding the
applicant's participation in the AmeriCorps program to which he or she has applied.

OVERALL RECOMMENDATION
6.

What is your overall recommendation?

■ I recommend the applicant for AmeriCorps service.
■ I have some reservations, but I believe the applicant will succeed in serving with AmeriCorps.
■ I do not recommend this applicant for AmeriCorps service.
CONFIDENTIALITY STATEMENT
■

I AUTHORIZE the program and/or the Corporation for National and Community Service to identify me as the
source of this reference and to release a copy of this reference in its entirety upon request to the applicant.

■

I DO NOT authorize the program and/or the Corporation for National and Community Service to identify me as
the source of this reference, nor do I authorize the release of a copy of this reference in its entirety to the
applicant.

Your Signature: ________________________________________________________________________________

PLEASE RETURN THIS FORM, IN AN ENVELOPE SIGNED
ACROSS THE SEAL, DIRECTLY TO THE APPLICANT.
12

1

REFERENCE FORM
TO THE APPLICANT:
Please complete the information below and give this form to each of your references. You should select people who
know you well and who are familiar with your personal background, education, employment, and/or professional
skills. You should not ask a family member, peer, classmate, co-worker, or friend to serve as a reference.
Consider asking work supervisors, clergy, teachers, counselors, coaches, or someone else familiar with your motivation and community involvement.
Your reference should complete this form, seal it in an envelope, sign his or her name across the seal on the outside
of the envelope, and return it to you to include with the application you send to AmeriCorps.
Applicant’s Name: ______________________________________________________________________________
LAST

FIRST

MIDDLE

Address:______________________________________________________________________________________
(IF P.O. BOX, ALSO GIVE NUMBER AND STREET)

Home Phone: (_____)__________________

CITY

STATE

ZIP CODE

Work Phone: (_____)____________________

INDICATE THE PROGRAM THAT YOU ARE APPLYING TO (check only one):
■
■

AmeriCorps NCCC
AmeriCorps VISTA
Program name: ____________________________________________________________________
Program address: __________________________________________________________________

■

AmeriCorps State and National:
Program name: ____________________________________________________________________
Program address: __________________________________________________________________

TO THE PERSONAL REFERENCE:
AmeriCorps engages more than 70,000 Americans a year in results-driven service sponsored by thousands of local
and national nonprofits, public agencies, and faith-based and community organizations. AmeriCorps members help
communities meet critical challenges in the areas of education, public safety, the environment, and other human
needs. In return, AmeriCorps members may earn a Segal AmeriCorps Education Award that helps pay for college or
pay back student loans.
The person named above is applying to be an AmeriCorps member. The applicant has indicated that you would be
able to evaluate his or her qualifications and provide us with a candid recommendation.
The success of AmeriCorps largely depends upon an appropriate match between programs and
members. Considerable value is placed on personal references during the application review and selection process.
Your input is greatly appreciated.
Name of Reference: ____________________________________________________________________________
LAST

FIRST

MIDDLE

Position/Title: _________________________________________________________________________________
Organization/Institution: _________________________________________________________________________
Address: _____________________________________________________________________________________
(IF P.O. BOX, ALSO GIVE NUMBER AND STREET)

CITY

STATE

ZIP CODE

Home Phone: (____)______________ Work Phone (____)______________ E-mail: _________________________
13

2
KNOWLEDGE OF THE APPLICANT
How long have you known the applicant? Years:__________________ Months: ____________________
In what capacity have you known the applicant?

■ Job Supervisor/Employer

■ High School Teacher

■ Clergy

■ Volunteer Supervisor

■ College Instructor

■ Coach

■ Other (specify): ____________________________________________________________________________
Please describe the situation in which you know the applicant.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

WORK PERFORMANCE
1.

Please comment on such qualities as the applicant's level of dependability, initiative, and ability to work with
minimal supervision and as a member of a team.

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
2. In your judgment, how competent is this applicant, as demonstrated by work in the community,
in school, on the job, or in a position of responsibility? Please check one.

■
■
■
■
■

Outstanding performance
Above average performance
Satisfactory
Below average performance
Unsatisfactory performance

14

3
RELATIONSHIPS WITH OTHER PEOPLE
3.

AmeriCorps members must serve and communicate with people of varied cultural, economic, educational, racial,
and religious backgrounds. Please comment briefly on the applicant's relationships with others and ability to
work as a member of a team.

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

EMOTIONAL MATURITY
4.

Please comment on the applicant's ability to adapt and work under difficult and changing conditions.

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

ADDITIONAL COMMENTS AND SUPPORTING INFORMATION
5.

If you wish, use additional paper to explain any of your ratings, and anything else about this
applicant that you feel is relevant to serving in AmeriCorps-such as the applicant's desire to serve others,
maturity, work ethic, flexibility, and dependability. Explain any reservations that you have regarding the
applicant's participation in the AmeriCorps program to which he or she has applied.

OVERALL RECOMMENDATION
6.

What is your overall recommendation?

■ I recommend the applicant for AmeriCorps service.
■ I have some reservations, but I believe the applicant will succeed in serving with AmeriCorps.
■ I do not recommend this applicant for AmeriCorps service.
CONFIDENTIALITY STATEMENT
■

I AUTHORIZE the program and/or the Corporation for National and Community Service to identify me as the
source of this reference and to release a copy of this reference in its entirety upon request to the applicant.

■

I DO NOT authorize the program and/or the Corporation for National and Community Service to identify me as
the source of this reference, nor do I authorize the release of a copy of this reference in its entirety to the
applicant.

Your Signature: ________________________________________________________________________________

PLEASE RETURN THIS FORM, IN AN ENVELOPE SIGNED
ACROSS THE SEAL, DIRECTLY TO THE APPLICANT.
15

QUESTIONS? CALL 1-800-942-2677
OR (TTY) 1-800-833-3722
Your World. Your Chance To Make It Better.
AmeriCorps.gov

AMERICORPS APPLICATION
OPTIONAL INFORMATION
HOW DID YOU HEAR ABOUT AMERICORPS? You may check more than one.
■ AmeriCorps representative

(Service/career fair, conference, information session)

■
■
■
■
■
■
■
■
■
■
■
■
■
■

Armed Forces
Social Media
Current or former AmeriCorps member
Friend/Relative
Internet/E-mail
Other service organization
Radio story
Poster at school
College guidance office/Placement office
High school guidance counselor
Newspaper/Magazine article
Radio advertisement
Received information in the mail
Other (specify) ______________________

Have you previously served with an AmeriCorps program? Check all that apply:
■ AmeriCorps State/National
■ VISTA
■ NCCC
WHAT IS YOUR ETHNICITY? (optional)

■ Hispanic or Latino

■ Not Hispanic or Latino

WHAT IS YOUR RACE? (optional) Mark one or more:
■

■

■
■
■

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

16

AMERICORPS APPLICATION

WHERE TO SEND YOUR
APPLICATION
Please send your application directly to the AmeriCorps program where you wish to serve. To get the
address for the AmeriCorps program where you wish to serve, or to apply online, visit the AmeriCorps
website at AmeriCorps.gov. If you don't have Internet access, you can still get program information or
apply by calling 1-800-942-2677.

Print out and use this application OR go to the My AmeriCorps Portal and apply online
https://my.americorps.gov

If you are applying to AmeriCorps NCCC, send your application to:
AmeriCorps NCCC
1201 New York Avenue, N.W.
Washington, DC 20525

17