AmeriCorps Application
May 22, 2013
First Name:
 MI:
 Last Name:
Email:
 Home Address:
 City:
County: (not COUNTRY)
 State:
 Zip Code:
Phone:
 Cell Phone:
 Citizen of:
Driver's License Number:
 State Issued:
Permanent Mailing Address (if different from above):
Address:
 City:
 State:
Zip Code:
 Date of Birth:
Optional Information:
Gender:
Male Female

Citizenship Status:

I am a US Citizen or National *
I am a Lawful Permanent Resident Alien of the United States **
I am not a US Citizen/National/Lawful Permanent Resident Alien of the US

* 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, including Swains Island.

** Generally, you are a Lawful Permanent Resident Alien of the US fi 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) an 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.

Have you previously participated in an AmeriCorps program?
yes no
If yes, please provide the following:
Position Held:
 Supervisor's Name:
 Contact Information:
The member understands that s/he may serve a maximum of two terms of service as an AmeriCorps member and may receive no more than two education awards. S/he may serve a third term of service in another National Service program (VISTA,Promise Fellows) however, education awards are received for the first two terms only.

High School Status:

  I have received a high school diploma or its equivalent
Or
  I agree to obtain a high school diploma or its equivalent before using my education award, and I did not drop out of elementary or secondary school to enroll in the program.

How did you hear of Northwest Youth Corps? (Required check all that apply. Hold down CTRL or Apple key to select more than 1)
   If Other, please specify:
1. I am interested in an AmeriCorps member position with the following program(s): (Please make sure you can commit to the entire length of the program)
Please rank your choices with Choice No. 1 being your highest preference.
Choice No. 1
Choice No. 2
Choice No. 3
Choice No. 4
2. Education and Training (please include High School information):
SchoolDates AttendedDegree
3. Certification:
Some NYC AmeriCorps Members must hold First Aid and CPR certifications before starting their term of service. Check all areas below in which you are currently certified.
Wilderness First Aid (WFA) Wilderness First Responder (WFR) Standard First Aid
Advanced First Aid First Responder EMT
WEMT No First Aid Training at all
CPR
CPR No CPR
Other Related Certifications
Life Guard Water Safety Insructor
Other - (Please list other if applicable.)
4. Background:
Have you had your driver's license for three years or more?
yes no
Some AmeriCorps positions require a valid driver’s license and driving record acceptable to NYC and NYC’s insurance carrier.
5. Legal:
Answer the following questions fully. Existence of criminal conviction/adjudication may or may not, depending on the circumstance, disqualify you from consideration. However, any intentional misrepresentation or omission will disqualify you.
Have you had any driving citations during the last three years?
yes no
Have you ever been:
Convicted of any criminal offense by a civilian court or by military authorities?
yes no
Are you currently under charges for any offenses?
yes no
On probation or parole?
yes no
If you answered yes to any of the questions above, please provide the following information:
Date:Place (City/State):
Charge:Action Taken:
Court, Probation or Parole Officer:Address:
City:State:
Zip Code:
6. Position Description:
Have you examined the description for this position?
yes no
Do you understand and can you meet the requirements of this position (with or without reasonable accommodation)?
yes no
7. Communication:
Do you possess interpretive skills in American Sign Language?
yes no
Please list any languages in which you are fluent other than English.
Application Requirements
  • Completed and Electronically Signed Application
  • Cover Letter
  • Resume: Including Employment History
  • Four references (two letters of recommendation may substitute for two references)
Certification and Release
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. By signing this application I agree, if asked, to provide information to verify the accuracy of my completed form. I understand that misinformation or omission of information could result in disqualification and/or release from AmeriCorps Programs and forfeiture of benefits I may receive as a result of my enrollment.

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 Service without your prior written permission. NYC policy prohibits the use of illicit drugs, alcohol, or tobacco products while working with youth; AmeriCorp members must maintain a substance-free lifestyle throughout their employment period.

All position offers will be contingent upon:
   Proof of U.S citizenship, or proof that you are authorized to work legally in the U.S.
   Proof of High School graduation (or equivalency)
   Criminal background check
   National Sex Offender Public Registry Check
   Continued program funding from the Corporation for National Service

Some positions also require:
   A valid driver's license and driving record acceptable to NYC and NYC's insurance carrier.

To complete application requirements online, you may attach your documents using this form below. If you have problems using this form, contact us at work@nwyouthcorps.org.

Upload and Attach Cover Letter
Upload and Attach Your Resume
Upload and Attach References
Upload and Attach Answers
to Supplemental Questions
(if there are any)


If submitting on line, by typing your name below you certify that the statements made on this application are true and accurate.

Name of Applicant:
NYC is an Equal Opportunity Employer. Minorities and persons with disabilities encouraged to apply. DISABILITY ACCOMMODATIONS PROVIDED UPON REQUEST.

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