National Service Trust Enrollment Form

Completing this form enrolls a serving member in the National Service Trust, which 

makes the member eligible for a Segal AmeriCorps Education Award upon successful 

completion of his or her term of service. It also provides the Corporation for National and 

Community Service (CNCS) with basic demographic data. This form may be filled out 

on paper or electronically.

PART 1

Member: Please Complete and Sign

1. Name Last First MI

2. Date of Birth Month Day Year

3. Social Security Number

4. Citizenship Status

I am a U.S. Citizen or National *

I am a Lawful Permanent Resident Alien of the United States **

I am an Asylee ***

*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 if you are a US 

permanent resident with (i) a Permanent Resident Card, USCIS Form I-551; (ii) an Alien 

Registration Receipt Card, USCIS Form I-551, (iii) a passport indicating that the USCIS 

has approved it as temporary evidence of lawful admission for permanent residence; or 

(iv) a form I-94 indicating that the USCIS has approved it as temporary evidence of 

lawful admission for permanent residence. NOTE: A student visa does not confer 

resident status.

*** You are an asylee if you have a Form I-94 with asylum granted stamp; form I-766 

with Category “A5”, “A5”, or “A-5”; or an Order of the Immigration Judge granting

asylum.

5. School Status 

What is the highest level of education you have completed?

Less than high school 

High school diploma/GED

Technical school/apprenticeship/vocational

Some college

Associates degree (AA)
College graduate

Graduate degree (e.g. MA, PhD, MD, JD)

 If you do not have a high school diploma or its equivalent:

I agree to obtain a high school diploma or its equivalent, and I did not drop 

out of elementary school or secondary school to enroll in the program.

I am exempt from the requirement to have a high school diploma, due to: 

If you have some college:

 Choose the most recent school you attended

 

If school is not listed, provide name here 

 

Type of degree, diploma, or certificate 

If you have an Associate’s degree:

 Choose the school from which you received your most recent Associate’s degree

 

 If school is not listed, provide name here 

 Type of degree, diploma, or certificate 

If you have a Bachelor’s degree:

 Choose the school from which you received your most recent Bachelor’s degree

 

 If school is not listed, provide name here 

 Type of degree, diploma, or certificate 

If you have a graduate degree:

 Choose the school from which you received your most recent graduate degree

 

 If school is not listed, provide name here 

 Type of degree, diploma, or certificate 

6. Current Address (All information will be sent to you at this address until you notify

CNCS of a change of address.) 

Number and Street

City

State
Zip Code

Email Address

Home Phone

Business Phone

Ext

7. Permanent Address (Name and address of person through whom you can always 

be reached once you leave the program.) Check here if same as current address.

Last

First

MI

Number and Street

City

State

Zip Code

Email Address

Home Phone

Business Phone

Ext

8. Have you previously enrolled in an AmeriCorps, Silver Scholar, or Serve 

America Fellow Program? No Yes How many times? 

9. Have you ever been terminated/released 'for cause' by any AmeriCorps, Silver 

Scholar, or Serve America Fellow program? No Yes 

10. Education Award Limitations. I understand that I may not receive more than the 

aggregate value of two full-time education awards and that upon successful completion of 

the term of service, I will receive only that portion of the education award for which I am 

eligible, which may be all or a part of an education award, or no education award, 

pursuant to 45 CFR § 2526.55.
PART 2

Member Enrollment Certification

By signing this enrollment form I agree, if asked, to provide documentation to verify the 

accuracy of the information I have provided in this form. I understand that a knowing and 

willful false statement on this form can be punished by one or more of the following: a 

fine or imprisonment or both under 18 U.S.C. § 11, exclusion from participation in 

federal programs, and forfeiture of benefits I may receive as a result of my enrollment or 

other actions authorized by the Civil Fraud Remedies Act, 31 U.S.C. §§ 381-3812.

Member’s Signature

Date

PART 3

Member: Please Answer the Following Questions

CNCS gathers information about sex, race, ethnicity, and other demographic information 

to ensure the agency has the most complete and inclusive data on national service 

participants. This information is confidential, and will solely be used for data analysis to 

assist us in ensuring we serve all Americans equally. The information you provide will 

not be used in any way to determine or affect any federal benefit. Your responses are 

required in order to be enrolled as an AmeriCorps member, but will be kept confidential.

1. What is your sex?

Female Male

2. Are you registered to vote?

Yes No

Not sure Not eligible

3. Which of the following categories best describes your racial origin? (check all 

that apply)

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

Black or African American

White

Asian American

Other

4. Which of the following categories best describes your ethnic origin?

Hispanic or Latina/o Not Hispanic or Latina/o

5. What is your military, veteran, or family member status? (check all that apply)
Note: All honorably discharged veterans qualify for nomination for the Presidents 

Volunteer Service Award. 

I am a Veteran

I am an Active Duty Member of the U.S. Armed Forces 

I am a Member of the National Guard or Reserve Component

I am an immediate family member of a Veteran

I am an immediate family member of an Active Duty Member of the U.S. Armed Forces

I am an immediate family member of a National Guard Member or Reservist

I am not in the military, a veteran or a family member of someone in the US. Armed 

Forces

6. How did you hear about this program? (check all that apply.)

Recruitment brochure

College Resource Fair

Facebook ad or on Facebook in general

Twitter

Other social media platform. Please specify: 

AmeriCorps online recruitment system

Job search Web page

Article (online, newspaper, or magazine)

Advertisement in a newspaper/magazine

Guidance counselor/teacher

Parent/relative

Current or former AmeriCorps Member

Friend

TV commercial

Radio commercial

AmeriCorps recruiter/representative

Received information in the mail

AmeriCorps program poster

State Service Commission

Other. Please specify: 

Public reporting burden -- Estimated time to complete this form, including time for 

reviewing instructions and gathering and providing the information needed to complete 

the form, is 3 minutes for the Member section and 4 minutes for the Certifying Official 

section. Send comments regarding this burden or the content of this form to: 

Corporation for National and Community Service, National Service Trust, 121 New York 

Avenue, NW, Washington, DC 20525. CNCS informs the potential persons who are to 

respond to this collection of information that such persons are not required to respond to 

the collection of information unless it displays a currently valid OMB control number on 

this page of the form (see 5CFR 132.5(b)(2)(1))

Privacy Statement -- In compliance with the Privacy Act of 1974, the following 

information is provided: The primary purpose of the information is to successfully enroll 
a member in a term of service and the education award program. The evaluative

information will help CNCS improve its programming and services to members. 

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 this document. Your Social 

Security Number (SSN) is solicited under the authority of the Internal revenue Code (26 

U.S.C. 611(b) and 619) for use as a taxpayer identification number. Failure to disclose 

your actual SSN or any other information may result in a denial of your receiving an 

education award or it may delay the processing of your education award. 

All information obtained will be used only for official purposes, treated confidentially, 

and will not be disclosed unless there is a specific official need to know.

OMB Approval No.: 3045-0006

PART4

Enrollment Certifying Official: Please Complete and Sign

1. Program:

AmeriCorps State & National:

AmeriCorps National Direct

AmeriCorps State

AmeriCorps Education Award Program

AmeriCorps Tribe

AmeriCorps Territory

AmeriCorps VISTA

AmeriCorps National Civilian Community Corps

AmeriCorps Serve America Fellows

Other (Specify):

2. Type of Enrollment (Mark only one.)

Full-time (17 hours per year, or 365 days per year for VISTA)

VISTA Summer Associate (1-12 weeks)

Half-time (9 hours in no more than 2 years)

Half-time (9 hours in no more than 1 year)

Reduced half-time 675 hours

Quarter time 45 hours

Minimum time/Summer 3 hours

3. Will the member receive a living allowance?

Yes

No

4. Educational Award Amount: ____________
5. Program Information 

Name of Program or AmeriCorps NCCC Campus

Operating Site I.D. Number

Street Address

City

State

Zip Code

Business Phone

Ext

I understand that a knowing and willful false statement on this form can be punished by a 

fine or imprisonment or both under Section 11of Title 18. U.S.C or other actions 

authorized by the Civil Fraud Remedies Act, 31 USC 381-3812. 

Signature of Certifying Official Date

Name of Certifying Official (Please Print):