CORE Susquehanna AmeriCorps Member Application

We consider applications for positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of a non-job related condition or handicap, or any other legally protected status.

First name

Last name

Phone

Birthday

Month

Day

Year

Multi-line address

Country/Region

Address

Address - line 2

City

Zip / Postal code

1. Are you a U.S. Citizen or Permanent Resident Alien?

2. Do you have a current driver's license?

3. Do you have personal transportation?

4. How did you hear about CORE Susquehanna AmeriCorps?

5. Which site are you most interested in serving at?

6. What term are you interested in applying for?

7. Why do you wish to join AmeriCorps?

8. What skills and/or experiences do you have that will contribute to the CORE Susquehanna AmeriCorps program?

9. Provide a description of your community service experience.

Include social, professional, and neighborhood projects

10. Beginning with the most recent, please list all schools attended including high school, trade/technical school, college/university.

Please include school name, location (city, state) dates attended, area of study, and degree earned.

11. References

Please provide the name and phone number of two references - One of which must be a professional reference and one can be a personal reference who is not related to you. Please include your relationship with each reference.

12. Have you previously served with AmeriCorps? If "Yes" please tell us the date (month/year) that you started your previous AmeriCorps service.

13. Are you CPR and First Aid Certified?

14. Have you ever been convicted of any criminal offences?

15. Do you have any pending criminal charges?

16. If you answered “Yes” to questions 14 or 15, you may provide additional information or context below (optional):

For example, you may explain the nature of the charges, the date(s), and any steps taken since.

What is the best way to get in contact with you?

Signature

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By signing this application, I certify that I have not knowingly withheld any facts or circumstances that would detrimentally affect this application. It is agreed that any misrepresentation by me in this application will be sufficient cause for cancellation of a placement or for dismissal from service if I am placed.