**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 As yl ee *** *Citizens o f 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 I sland. **Generally , y ou are a Lawful Permanent Resident Alien of t he US if y ou are a US permanent resident with (i) a Permanent Resident Card, USCI S Form I

- 551; (ii) an Alien Registration Receipt Card, USCI S Form I

- 551, (iii) a passport indicating that the USCI S has approved it as temporary evidence of lawful admission f or 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 as yl ee if y ou have a Form I

- 94 w ith asy lum granted stamp; form I

- 766 with Category

“A5”, “A5”, or “A

- 5”; or an Order of the Immigration Judge granting asy lum. 5. School Status What is the highest level of education you have completed? Less than high school High school dipl oma/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 y ou attended If school is not listed, provide name here Ty pe of degree, diploma, or certificate If you have an Associate’s degree: Choose the school from which y ou received y our most recent Associate’s degree If school is not listed, provide name here Ty pe of degree, diploma, or certificate If you have a Bachelor’s degree: Choose the school from which y ou received y our most recent Bachelor’s degree If school i s not listed, provide name here Ty pe of degree, diploma, or certificate If you have a graduate degree: Choose the school from which y ou received y our most recent graduate degree If school is not listed, provide name here Ty pe of degree, diploma, or certificate 6. Current Address (All information will be sent to y ou at this address until y ou notify CNCS of a change of address.) Number and Street City StateZip Code

Email Address Home Phon e Business Phone Ext 7. Permanent Address (Name and address of person through whom you can always be reach ed 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 man y times? 9. Have you ever been terminated/released 'for cause' b y an y AmeriCorps, Silver Scholar, or Serve America Fellow program? No Yes 1 0 . Education Award L imitations. Iunderstand that Imay not receive more than the aggregate value of two full

- time edu cation 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 Iagree, if asked, to provide documentation to verify the accuracy of the infor

mation Ihave 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 m y 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 inform ation to ensure the agency has the mos t complete and inclusive data on national service participants. This information is confidential, and will solely be used for data anal ys is to assist us in ensuring we serve all Americans equally . The information y ou provide will not be used in an y wa y to determine or affect an y federal benefit. Your respons es are required in order to be enrolled as an AmeriCorps member, but will be kept confidential. 1. What is y our sex? Female Male 2. Are you registered to vote? Yes No Not sure Not eligible 3. W hich 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 y our 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 Act ive 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 y ou 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 sy stem 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 informati on nee ded to complete the form, is 3 minutes for the Member section and 4 minutes for the Certify ing Official section. Send comments regarding this burden or the content of this form to: Corporation for National and Community Service, National Service Tr ust, 121 New York Avenue, NW, Washington, DC 2 0 525. 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 display s a currentl y vali d 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 suc cessfully enrolla member in a term of service and the education award program. The evaluative

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

be shared with other agencies, such as the Social Security Administration, through computer matching agreements for the purpose of verify ing identity and citizenship status information provided by y ou 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 t axpay er identification number. Failure to disclose yo ur actual SSN or an y other information may result in a denial of y our receiving an education award or it may delay the processing of y our 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.: 3 0 45

- 0006

**PART4** Enrollment Certify ing 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. Ty

pe of Enrollment (Mark only one.) Full

- time (17 hours per year, or 365 day s per ye ar for VISTA) VI STA Summer Associate (1

- 12 weeks) Half

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

- time (9 hours in no more than 1 y ear) Reduced half

- time 675 hours Quarter tim e 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 Cit y 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 1 1of Title 18. U.S.C or other actions authorized by

the Civil Fraud Remedies Act, 31 USC 381

- 3812.

Signature of Certify ing Official Date Name of Certify ing Official (Please Print):