## Segal **Am eriCorps Education A**  **wa rd**  **Matching Program Commitment Form**  **Section I: Profile Information Name o**  **f Higher Education Institution**  **:**

_ ____________________________________ If the Ed Award Matching Program applies to a specific department or school, please list here :

______________________________________________ ________________________ We bsite: _____________________ City, State :

______________________________ ___ __________________________ **Primary Contact:**  Name : ____________________

_ Phone: ______________________ Fax: ________________________ E - mail: ______________________ Ma iling Address:

______________________ **President, Provost, or Dean that is signing Commitment Form**  **:** Name : _____________________ Phone:

______________________ Fax: ________________________ E - mail: ______________________ **Institution Profile:**  **Type (please check**  **one )**  **:** Public ____ Private _____ **Program Ty pes**  **( check all that apply** **) :**  2 Year ___ 4 Year ___ Graduate ____ **Is Your Institution Eligible to A**  **wa rd Federal Student A** **id Funds Based on (check all that apply** **):** Title IV___ VA Qualified ____**Is Your Institution (check all that apply ):** 

Faith - Based ______ Historically Black College/University _____ Tribal College ___

__ Hispanic Serving Institution ______ **Section II: Commitment Level P**  **rovide a detailed description of what your institution**  **is offering for the**  **Segal Am**  **eriCorps Ed**  **ucation Aw**  **ard Matching Program .**  This language will be posted on our website and should c l early outline your institution’s commitment to AmeriCorps alumni
. Include the amount of the dollar match along with any additional benefits that your institutio n will offer to AmeriCorps alumni
. **Pease note: Educational institutions must provide a minimum match of $1,000 to be**  **listed on the CNCS website. A dollar for dollar match is the preferred level of commitment from schools that participate in this program**  **P ercentage of the a** **ward that y our institution will match for an admitted A** **meriCorps a**  **lum ni**  **: __**

**______%.** Refer to FAQs for an explanation and current amount of the Segal AmeriCorps Education Award. (link to FAQs sheet). The Segal AmeriCorps Education Award is tied to the maximum amount of the U.S. Department of Education’s Pell Grant. To qualify for this competition, AmeriCorps alumni must have successfully completed their full term of service
. *Refer to FAQs for a listing of programs and required hours.
* VISTA Summer Associates and AmeriCor ps alumni who did not complete service and did not termi nate for compelling reasons are not eligible for this program. **Section III: Commitment Timeframe** This commitment to the Corporation for National and Community Service is valid for five (5) years from the date of signature on this agreement. This agree ment will be up for renewel on _________, 2017. **If the institution needs to terminate this agreement, CNCS will be notified to in order to delete the website listing; otherwise students will continue to contact the institution.**  CNCS reserves the right to delete the website listing for any institution not in compliance with the Ed Award Matching Program requirements. **Please return this form**  **to:** INSERT EMAIL ADDRESS OR Fax: 202.606.3475 Ph: TBD