Appalachia CARES AmeriCorps Application

Appalachia CARES AmeriCorps Application
Personal Profile
Full Legal Name*

First NameMiddle NameLast Name
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?*

YesNo
Date of Birth*

MonthDayYear
Date
Other name you go by (if not first name)
Preferred Pronouns (select all that apply)*

she/herhe/himthey/themno preference
Email Address*
Phone Number*

Area CodePhone Number
Current Address*

Number and Street (do not include a PO box)

Address continued (if needed)

CityState

Zip Code
Note: Upon enrollment, you will submit your current address again, so this will only be used for our files - no mail will be sent to this address.
A valid driver's license or non-driver photo ID is required. Please upload a clear photo of the front your driver's license or ID card.*

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Position Information

Please provide some additional information so your application can be processed accurately and efficiently.
Name of service site (organization or agency) you are applying for:*
Please list the actual service location. Appalachia CARES is the program, NOT the service site.
Physical location (city, state) of organization or agency you are applying for:*
Some of our partners have multiple parks, field offices, departments, etc.
Earliest date you are available to begin service (does not guarantee start date):*

MonthDayYear
Date
How did you hear about this position?*
Education
Check the highest level of education that you will have completed by the time you are planning to serve in AmeriCorps:*

Some high schoolHigh school diploma / GEDTechnical school / apprenticeshipAssociate's degreeSome collegeBachelor's degreeGraduate degreeOther

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

	Name of School	City, State	Dates attended	Major/Study Area	Type of Degree or Certificate	Date received or expected
A.
B.
C.
D.

Community Service

Previous service is not always a requirement, but please explain if you have no service experience.
Describe how you have reached out to help others and/or how you have been involved in your own community. Explain why you decided to serve or get involved, and what you received in return - that is, what you learned or how if made you feel. Think in broad terms. List your most recent activity first. Examples - Serving in neighborhood, school, religious, social, professional or other volunteer groups; helping out with community service projects; or participating in less formal activities.*

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	Organization Name	Dates Involved	Hours per month	Phone	City, State
A.

Description of Involvement:

	Organization Name	Dates Involved	Hours per month	Phone	City, State
B.

Description of Involvement:
Motivational Statement
We would like to understand more about you and your reasons for applying to AmeriCorps. Take a few minutes and consider those experiences which have made you the person you are today. Please share with use one of these experiences and how it sparked your interest in community service.*

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Employment
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. Include self-employment, internships/fellowships, home management, and full or part-time paid or unpaid work experience. You may attach a resume if it includes all the requested information below. Please type "see attached resume" in the first employment field if you do so.
Upload Resume (optional)

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Explain any period of time 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
Please list any skills or areas in which you have had training or experience that are relevant to this position, and indicate how you gained those skills. If this is covered on your resume, please type "see attached resume" in the box below.*
Do you know or have you studied any language(s) other than English to the point of proficiency? If yes, please indicate the language and level of speaking and writing ability.*

Yes - complete next questionNo
Please list the language(s), level of speaking ability, and level of writing ability.
National Service Criminal History Check
The AmeriCorps application process requires a National Service 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 will investigate for past sexual offenses and violent crimes, or crimes that would have a direct bearing on the service position.

The following will immediately disqualify an applicant for AmeriCorps service: murder conviction, sex offender conviction, refusal to undergo the criminal history process, and/or intentional misrepresentation or omission of criminal history.

The following could potentially disqualify an applicant for a position with the Appalachia CARES program and/or the selected service site: criminal charges within one year of applying or criminal history that has a direct bearing on service activities (as deemed by the Appalachia CARES program or the service site partner).

The National Service Criminal History Check will entail a National Sex Offender Registry check, a state of service check (Tennessee is included in the FBI check), a state of residence check (for applicants residing out of state at the time of application), and a fingerprint-based Federal Bureau of Investigation (FBI) check. Repositories or vendors used to conduct the checks may include: Identogo, Fieldprint, Truescreen, and NSOPR.gov. All instructions and requirements will be provided by the Appalachia CARES program during the enrollment process, and the applicant is responsible for completing all components of the criminal history check by the deadline given. Additional background check requirements and/or enrollment requirements, such as drug tests, may be required by the service site and will be communicated to the member during the enrollment process.

National Service Criminal History Check results will be reviewed and adjudicated by program staff, and if necessary, the selected service site. Selection for service is contingent upon review of National Service Criminal History check component results. Applicants will be given a reasonable opportunity to review and challenge the accuracy of the results, and/or provide further explanation and documentation to dispute results. All components (including completion of the checks, results received, adjudication, and any disputes or further review resolved) must be completed and on file PRIOR to the member being cleared to serve. Applicants and sites will be notified in writing (email) when they are clear to start.
I have read and understand the National Service Criminal History Check policy.*

Yes
I allow the AmeriCorps program to complete the required components of the National Service Criminal History check.*

Yes
Have you ever been convicted as an adult, or adjudicated as a juvenile offender, of any criminal offense by either a civilian or military court, other than minor traffic violations?*

YesNo
Are you currently facing charges for any offense or on probation or parole?*

YesNo
If you answered "yes" to the questions above regarding criminal history, please provide the following information:
Additional information or explanation:
Certification
By submitting this application electronically, 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 positions, I may be required to submit to a physical examination, including drug or alcohol testing. Additional background and security checks may also be conducted by certain partner organizations.*

I certify, agree, and understand.
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. 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 will not otherwise be disclosed to entities outside of AmeriCorps and the Corporation for National and Community Service without your prior written permission.

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. If you believe you have been subjected to discrimination on these grounds by CNCS, AmeriCorps, or one of its grantees, you may contact our Office of Civil Rights and Inclusiveness at 202-606-7503 or email eo@cns.gov.
Signature*

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Please sign using a mouse or touch screen
Printed Name*
Date*

MonthDayYear
Date
Parent / Guardian Approval and Signature for Applicants Under 18 Years of Age:
I have reviewed this application and I authorize my son / daughter / legal ward to apply to AmeriCorps.
Parent or Guardian Signature

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Parent / Guardian Printed Name
Parent / Guardian Date Signed

MonthDayYear
Date
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Appalachia CARES AmeriCorps Application

Personal Profile

Position Information

Education

Community Service

Motivational Statement

Employment

Skills and Experience

National Service Criminal History Check

Certification