Applicant Information

First Name:

Last Name:

Address:

City:

State:

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Zip Code:

Phone Number:

Email Address:

Are you interested in Full Time, Part Time, or Quarter Time?

Full TimePart TimeQuarter Time

Will you be 18 years old or older at the start date of service?

YesNo

Date of Birth:

Are you a US Citizen, national, or lawful permanent resident?

YesNo

Education

Do you have a Diploma, GED, or HiSet?

YesNo

Year Awarded:

If Yes, who was the awarding entity?

Availability

Sunday:

Monday:

Tuesday:

Wednesday:

Thursday:

Friday:

Saturday:

Employment History

Please describe your employment record. List the last five positions you have held, beginning with the most recent. Be sure to include any experience you have which may be relevant to your service as an AmeriCorps member. You may submit a resume if you wish.

Employer:

Dates:

Position:

Phone Number:

Supervisor:

Reason for Leaving:

Employer:

Dates:

Position:

Phone Number:

Supervisor:

Reason for Leaving:

Employer:

Dates:

Position:

Phone Number:

Supervisor:

Reason for Leaving:

Employer:

Dates:

Position:

Phone Number:

Supervisor:

Reason for Leaving:

Employer:

Dates:

Position:

Phone Number:

Supervisor:

Reason for Leaving:

Are you currently on lay-off status, subject to recall?

YesNo

Volunteer Experience

List and describe any volunteer experience and/or community involvement.

Activity Description:

Organization:

Dates:

Activity Description:

Organization:

Dates:

Activity Description:

Organization:

Dates:

Activity Description:

Organization:

Dates:

Personal Statement

Why do you want to participate in East St. Louis AmeriCorps?

What will you do, as a participant, to ensure the success of the East St. Louis AmeriCorps program?

Briefly explain how your professional, volunteer, educational, and life experiences would be helpful to you as an AmeriCorps member.

Felony Convictions

Have you ever been convicted of a felony?

NoYes

If yes, please list the type of conviction, date, and disposition for each conviction.

References

Please list at least two professional and two personal references.

Name:

Years Known:

Contact Number:

Type:

PersonalProfessional

PersonalProfessional

PersonalProfessional

PersonalProfessional

Optional Demographic Information

Ethnic Background:

American Indian/Alaskan NativeAsian/Pacific IslanderBlack/African AmericanHispanicWhite/CaucasianMultiple EthnicityOtherPrefer not to answer

Gender Identity:

FemaleMaleTransgenderOtherPrefer not to answer

Do you have any special needs that require accomodation?

YesNo

If yes, please specify:

Does your family receive public assistance (e.g. TANF, Food Stamps, Medical Card)?

YesNo

If yes, please specify:

Annual Household Income:

How many people reside in your household?

Signature:

Clear

Date:

Submit

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