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AmeriCorps Member Application

Print out and use this application OR apply online through the My AmeriCorps Portal at 

my.americorps.gov

PLEASE READ THIS INFORMATION BEFORE COMPLETING THE APPLICATION

• This application may be used to apply for AmeriCorps State and National, AmeriCorps 

VISTA, AmeriCorps NCCC and FEMA Corps programs. However, if you are applying to an 

AmeriCorps State or National program, you should first check with the program to see if it 

requires additional or alternate forms. To determine specific application requirements, visit 

the AmeriCorps website at AmeriCorps.gov or call 1-800-942-2677.

• If you’re applying to more than one AmeriCorps program, complete the entire application 

except for question 11 and the final “Certification” Section. Make one copy of the 

application for each program. Then, answer question 11 and sign each copy separately 

before mailing.

• You may use additional sheets of paper to provide more detailed information that will 

not fit on this application form. Enclose everything in the final application packet that 

you submit.

• Two reference forms are enclosed in this packet. They are an important part of your 

application and must be submitted with your application. Your application cannot 

be considered without references. If you are applying to multiple programs and using 

the same person as a reference, please remind them to make multiple copies after 

completing the reference form.

• Make a copy of your application for your personal records before you send it in.

• Send your application to the right place. Please refer to the back cover for instructions.

• This publication is available upon request in alternative formats for people with disabilities. 

Call 1-800-942-2677; TTY: 1-800-833-3722.

Public reporting burden for this collection of information is estimated to average 1.25 hours per submission, 

including reviewing instructions, gathering and maintaining the data needed, and completing the form. 

Comments on the burden or content of this instrument may be sent to the Corporation for National and 

Community Service (operating as “AmeriCorps”), 250 E Street SW, Washington, DC 20525. AmeriCorps 

informs people who may respond to this collection of information that they are not required to respond to 

the collection of information unless the OMB control number and expiration date displayed on page 1 are 

current and valid. (See 5 C.F.R. 1320.5(b)(2)(i).)

OMB# 3045-0054

Expires 4/30/2025
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PERSONAL PROFILE

1. Name __________________________________________________ __________________________________________________ ______________________

 Last First MI

2. AmeriCorps members must be a United States citizen, U.S. national or lawful permanent resident.

Are you a United States citizen, national, or lawful permanent resident alien?  No  Yes

If you are a lawful permanent resident alien and you received your card after January 1987, what is your registration number and card 

expiration date? __________________________________________________________________________________________________________________

3. Final four numbers of social security number: ____________________________________ (You will provide your full social security number later in the process.)

4. Date of Birth _______________________ ___________ ___________ 5. Place of Birth _______________________ ___________ ________________

 Month Day Year City State Country

6. What is your sex?

 Female  Male  Nonbinary  Prefer not to answer

7. Earliest date you are available to begin service _____________________________________ ___________________________ _________________

 Month Day Year

8. Current Address (All information will be sent to you at this address until you notify AmeriCorps of a change of address.)

Number and Street _______________________________________________________________________________________________________________

City _____________________________________________________________________ State ____________________ Zip Code ____________________

Home Phone ____________________________________________________ Work Phone ____________________________________________________

Cell Phone ____________________________________________________ Email ____________________________________________________________

9. Are you moving within the next six months?  Yes  No If yes, when*? _______________________ ____________ ________________

*Please notify us of new address at time of move. Month Day Year

10. Emergency Contact/Permanent Address (if different than above): Please give the name and address of a person through whom you can always be reached.

Name _____________________________________________________________ Relationship _________________________________________________

Number and Street _______________________________________________________________________________________________________________

City _____________________________________________________________________ State ____________________ Zip Code ____________________

Home Phone ____________________________________________________ Work Phone ____________________________________________________

Cell Phone ____________________________________________________ Email ____________________________________________________________

11. Which AmeriCorps program are you applying to? Check only one. If you are applying to more than one AmeriCorps program, fill this 

in after you copy your application. Enter the program information on each application.

 AmeriCorps State and National

Members who are over the age of 17 serve either in teams or individually through national and community-based private and 

public organizations. Members help solve community problems through direct and indirect service in the areas of disaster services, 

economic opportunity, education, environmental stewardship, healthy futures, and human needs, such as working with veterans 

and military families.

Program Name ___________________________________________________________________________________________________________________

Program Address _________________________________________________________________________________________________________________

 AmeriCorps VISTA (Volunteers in Service to America)

Members who are at least 18 years old serve through private organizations and public nonprofit agencies, addressing issues related 

to poverty such as financial security, hunger, homelessness and helping, disadvantaged youth, community development, and 

employment. Members create resources and long-term sustainable benefits at a community level.

Program Name ___________________________________________________________________________________________________________________

Program Address _________________________________________________________________________________________________________________

 AmeriCorps NCCC (National Civilian Community Corps)

Members ages 18 to 24 serve in a 10-month team-based residential program to complete a variety of service projects in the areas of 

education, disaster services, the environment, and other unmet needs. Members often travel to projects throughout their region.

 Fall Class (September/October start dates)  Winter Class (January start dates)

 FEMA Corps (A branch of AmeriCorps National Civilian Community Corps)

Members ages 18 to 24 serve in a 10-month team-based residential program to complete projects in disaster preparedness, 

response, and recovery. Members often travel to projects throughout their country.

 Fall Class (September/October start dates)  Winter Class (January start dates)

12. Check the highest level of education that you will have completed by the time you are planning to serve in AmeriCorps. (Check only one.)

 Some high school  Some college  Graduate degree

 High school diploma or GED  Associate’s degree  Other (please specify): ___________________________

 Technical school/Apprenticeship  Bachelor’s degree _________________________________________________
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13. List all schools after high school that you have attended, including trade or technical schools, military training and employment 

training programs.

Name of School 

(List most recent first)

Location of School 

(City/State)

Dates Attended

Major or Area 

of Study

Type of Degree 

or Certificate

Date Received 

or Expected From

Mo./Yr.

To

Mo./Yr.

COMMUNITY SERVICE (Previous service is not always a requirement.)

14. Describe how you have reached out to help others and/or how you have been involved in your own community. Explain why you 

decided to serve or get involved, and what you received in return-that is, what you learned or how it made you feel. Think in broad 

terms. List your most recent activity first. Attach a separate sheet of paper if you need more space. (Your involvement could include 

serving in neighborhood, school, religious, social, professional, or other volunteer groups; helping out with community service projects; 

or participating in less formal activities.)

_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

A. Dates of involvement

From: ____________________________________ To: ____________________________________ Hours per month: _____________________________

 Month/Year Month/Year

Organization Name: _________________________________ Location: ________________________________ Phone: _________________________

Description of Involvement: __________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

B. Dates of involvement

From: ____________________________________ To: ____________________________________ Hours per month: _____________________________

 Month/Year Month/Year

Organization Name: _________________________________ Location: ________________________________ Phone: _________________________

Description of Involvement: __________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

MOTIVATIONAL STATEMENT

15. We would like to understand more about you and your reasons for applying to AmeriCorps. Take a few minutes and consider those 

experiences which have made you the person you are today. Please share with us one of these experiences and how it sparked your 

interest in community service. If you need additional space, attach a separate piece of paper and limit your total response to 500 words.

_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________
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EMPLOYMENT

Beginning with the most current or most recent position, list and briefly describe the last four positions you have held or your last ten years 

of employment. Begin with the current or most recent and go back ten years. Include self-employment, internships/fellowships, home 

management, and full- or part-time paid or unpaid work experience. (You may attach a resume instead if it addresses the information requested below.)

Name and Address of Employer Dates Job Title and Duties

A. Organization

Name ____________________________________

City/State _________________________________

Supervisor

Name ____________________________________

Phone ____________________________________

Email _____________________________________

From ____________________

 Mo./Yr.

To ______________________

 Mo./Yr.

Hrs./week _______________

Title _________________________________________________________

Duties ______________________________________________________

_____________________________________________________________

Reason for leaving __________________________________________

_____________________________________________________________

B. Organization

Name ____________________________________

City/State _________________________________

Supervisor

Name ____________________________________

Phone ____________________________________

Email _____________________________________

From ____________________

 Mo./Yr.

To ______________________

 Mo./Yr.

Hrs./week _______________

Title _________________________________________________________

Duties ______________________________________________________

_____________________________________________________________

Reason for leaving __________________________________________

_____________________________________________________________

C. Organization

Name ____________________________________

City/State _________________________________

Supervisor

Name ____________________________________

Phone ____________________________________

Email _____________________________________

From ____________________

 Mo./Yr.

To ______________________

 Mo./Yr.

Hrs./week _______________

Title _________________________________________________________

Duties ______________________________________________________

_____________________________________________________________

Reason for leaving __________________________________________

_____________________________________________________________

D. Organization

Name ____________________________________

City/State _________________________________

Supervisor

Name ____________________________________

Phone ____________________________________

Email _____________________________________

From ____________________

 Mo./Yr.

To ______________________

 Mo./Yr.

Hrs./week _______________

Title _________________________________________________________

Duties ______________________________________________________

_____________________________________________________________

Reason for leaving __________________________________________

_____________________________________________________________

Explain any period of time greater than six months not accounted for by AmeriCorps, Peace Corps, work, school, or military service. 

Or, explain why you have no employment history.

_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________
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SKILLS AND EXPERIENCE

18. Listed below are skill areas that some programs find useful and may seek in AmeriCorps applicants. Indicate the skill areas in which 

you have had training or experience, including volunteer or community service experience, and indicate how you gained those skills.

EXAMPLE:  Public Speaking: Club President

 Architectural Planning: ________________________________________  Law: _________________________________________________________

 Business/Entrepreneur: ________________________________________  Leadership: ___________________________________________________

 Communications: _____________________________________________  Medicine: ____________________________________________________

 Community Org./Development: _______________________________  Public Health: _________________________________________________

 Computers/Technology: ______________________________________  Public Speaking: ______________________________________________

 Conflict Resolution: ___________________________________________  Recruitment: _________________________________________________

 Counseling: __________________________________________________  Teaching/Tutoring: ____________________________________________

 Education: ___________________________________________________  Trade/Construction: ___________________________________________

 Fine Arts/Crafts: _______________________________________________  Writing/Editing: _______________________________________________

 First Aid: ______________________________________________________  Youth Development: __________________________________________

 Fundraising/Grant Writing: _____________________________________  Other (specify): _______________________________________________

19. Do you know or have you studied any language(s) other than English?  Yes  No

Language(s) _______________________________________________________________________ Number of years studied or spoken ____________

Speaking Ability  Poor  Fair  Good  Excellent

Writing Ability  Poor  Fair  Good  Excellent

20. In the space below or on a separate sheet of paper, provide any additional skills and experience that may be helpful in evaluating 

your application, including other languages spoken.

_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

21. Do you have a valid driver’s license?  Yes  No License # ____________________________________ State _______________

(This is a requirement for some AmeriCorps programs, but not all.)
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CRIMINAL HISTORY

The AmeriCorps application process requires a criminal history check to ensure that community members with whom we work are 

protected, particularly children, individuals with disabilities, and individuals over 60 years old.

We will investigate for past sexual offenses and violent crimes, or crimes that would have a direct bearing on your service.

This background check will entail our search of the National Sex Offenders Registry and an FBI criminal history check, which will require 

you to be fingerprinted at Pre-Service Orientation.

You will not be permitted to serve or work with children, individuals with disabilities, or individuals over 60 years of age, without supervision 

until the history check is complete and you are cleared. The review process is not lengthy, and normally is completed within weeks.

Answer the following questions fully. Existence of a criminal conviction or juvenile adjudication may or may not, depending on the 

circumstances, disqualify you from consideration. However, any intentional misrepresentation or omission will disqualify you. Do not 

include minor traffic violations.

 I allow the AmeriCorps program to complete an NSOPW check and criminal background check

22. Have you ever been convicted as an adult, or adjudicated as a juvenile offender, of any criminal offense by either a civilian or 

military court, other than minor traffic violations?  Yes  No

Are you currently facing charges for any offense or on probation or parole?  Yes  No 

If no, skip to “Certification” below.

If you answered “yes” to any of the questions above, please provide the following information:

Date ________________ __________ __________ Place ___________________________________________________________ ____________________

 Month Day Year City State

Charge _____________________________________________________________________________________________________________________________

Action Taken ________________________________________________________________________________________________________________________

Court, Probation, or Parole Officer ____________________________________________________________ Phone ______________________________

Name ______________________________________________________________________________________________________________________________

Number and Street __________________________________________________________________________________________________________________

City _______________________________________________________________________ State ____________________ Zip Code ____________________

You may attach any additional information or explanation on a separate sheet.
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CERTIFICATION

If you choose to submit a paper application, your application must be certified with your original signature in ink. If you are applying to 

more than one AmeriCorps program, make a copy for each program that you’re applying to first, and then sign each one.

By signing this application, or by submitting it electronically if applying on-line, 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. Misinformation or omission of information 

could result in disqualification or termination as an AmeriCorps member. If I am selected for participation in some AmeriCorps programs, 

including AmeriCorps NCCC, I may be required to submit to a physical examination, including drug or alcohol testing. Background and 

security checks may also be conducted by some programs.

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. The 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 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 may also be provided to appropriate federal agencies and Department contractors 

that have a need to know the information for the purpose of assisting the Department’s efforts to respond to a suspected or confirmed 

breach of the security or confidentiality or information maintained in this system of records, and the information disclosed is relevant and 

unnecessary for the assistance. The information will not otherwise be disclosed to entities outside of AmeriCorps and AmeriCorps without 

prior written permission.

Signature _____________________________________________________________________________________ Date ________________________________

Print Name __________________________________________________________________________________________________________________________

For Parent or Guardian of Applicants Under 18 Years of Age: I have reviewed this application and I authorize my son/daughter/legal ward 

to apply to AmeriCorps.

Signature _____________________________________________________________________________________ Date ________________________________

Print Name __________________________________________________________________________________________________________________________

Relation _____________________________________________________________________________________ Phone ______________________________

Address _____________________________________________________________________________________________________________________________ (If P.O. Box, also give number and street)

City _______________________________________________________________________ State ____________________ Zip Code ____________________

AmeriCorps programs are available to all without regard to race, color, national origin, disability, age, gender, sexual orientation, religion, 

political affiliation, or other non-merit factors. Anyone believing he or she has been subjected to discrimination on these grounds by 

AmeriCorps, or one of its grantees, may email our Office of Diversity, Equity, Inclusion and Accessibility at eo@cns.gov.
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REFERENCE FORM

To the applicant

Please complete the information below and give this form to each of your references. Select people who know you well and who are 

familiar with your personal background, education, employment, and/or professional skills. You should not ask a family member, peer, 

classmate, co-worker, or friend to serve as a reference. Consider asking work supervisors, clergy, teachers, counselors, coaches, or 

someone else familiar with your motivation and community involvement.

Your reference should complete this form, seal it in an envelope, sign his or her name across the seal on the outside of the envelope, and 

return it to you to include with the application you send to AmeriCorps.

Applicant’s Name ______________________________________________ ______________________________________________ _____________________

 Last First MI

Address _____________________________________________________________________________________________________________________________ (If P.O. Box, also give number and street)

City _______________________________________________________________________ State ____________________ Zip Code ____________________

Home Phone _____________________________________________________ Work Phone _____________________________________________________

Indicate the program that you are applying to (check only one)

 AmeriCorps State and National

Program name ___________________________________________________________________________________________________________________

Program address _________________________________________________________________________________________________________________

 AmeriCorps VISTA

Program name ___________________________________________________________________________________________________________________

Program address _________________________________________________________________________________________________________________

 AmeriCorps NCCC or FEMA Corps

Program name ___________________________________________________________________________________________________________________

Program address _________________________________________________________________________________________________________________

To the personal reference

AmeriCorps engages hundreds of thousands members and volunteers in organizations dedicated to strengthening their community. 

AmeriCorps members help communities meet critical challenges in the areas of disaster services, economic opportunity, education, 

environment, and human needs, such as serving veterans and military families. In return, AmeriCorps members may earn a Segal 

AmeriCorps Education Award that helps pay for college or pay back student loans.

The person named above is applying to be an AmeriCorps member. The applicant has indicated that you would be able to evaluate his 

or her qualifications and provide us with a candid recommendation.

The success of AmeriCorps largely depends upon an appropriate match between programs and members. Considerable value is placed 

on personal references during the application review and selection process. Your input is greatly appreciated.

Reference’s Name ______________________________________________ ______________________________________________ ____________________

 Last First MI

Position/Title ________________________________________________________________________________________________________________________

Organization/Institution ______________________________________________________________________________________________________________

Address _____________________________________________________________________________________________________________________________ (If P.O. Box, also give number and street)

City _______________________________________________________________________ State ____________________ Zip Code ____________________

Home Phone _____________________________________________________ Work Phone _____________________________________________________

Email _______________________________________________________________________________________________________________________________

Knowledge of the applicant

How long have you known the applicant? Years ____________________ Months ____________________

In what capacity have you known the applicant?

 Job Supervisor/Employer  High School Teacher  Clergy

 Volunteer Supervisor  College Instructor  Coach

 Other (specify) ___________________________________________________________________________________________________________________
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Please describe the situation in which you know the applicant.

_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

Work performance

1. Please comment on such qualities as the applicant’s level of dependability, initiative, and ability to work with minimal supervision and 

as a member of a team.

_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. In your judgment, how competent is this applicant, as demonstrated by work in the community, in school, on the job, or in a position of 

responsibility? Please check one.

 Outstanding performance

 Above average performance

 Satisfactory performance

 Below average performance

 Unsatisfactory performance

Relationships with other people

3. AmeriCorps members must serve and communicate with people of varied cultural, economic, educational, racial, and religious 

backgrounds. Please comment briefly on the applicant’s relationships with others and ability to work as a member of a team.

_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

Emotional maturity

4. Please comment on the applicant’s ability to adapt and work under difficult and changing conditions.

_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

Additional comments and supporting information

5. If you wish, use additional paper to explain any of your ratings, and anything else about this applicant that you feel is relevant to 

serving in AmeriCorps, such as the applicant’s desire to serve others, maturity, work ethic, flexibility, and dependability. Explain any 

reservations that you have regarding the applicant’s participation in the AmeriCorps program to which he or she has applied.

6. What is your overall recommendation?

 I recommend the applicant for AmeriCorps service.

 I have some reservations, but I believe the applicant will succeed in serving with AmeriCorps.

 I do not recommend this applicant for AmeriCorps service.

Confidentiality statement

 I AUTHORIZE the program and/or AmeriCorps to identify me as the source of this reference and to release a copy of this reference 

in its entirety upon request to the applicant.

 I DO NOT authorize the program and/or AmeriCorps to identify me as the source of this reference, nor do I authorize the release 

of a copy of this reference in its entirety to the applicant.

Your Signature ______________________________________________________________________________________________________________________

PLEASE RETURN THIS FORM, IN AN ENVELOPE SIGNED ACROSS THE SEAL, DIRECTLY TO THE APPLICANT.
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OPTIONAL INFORMATION

How did you hear about AmeriCorps? You may check more than one.

 AmeriCorps representative

(Service/career fair, conference, information session)

 Armed Forces

 Current or former AmeriCorps member

 Friend/Relative

 Internet/Listserv/Email

 Newspaper/Magazine advertisement

 Other service organization

 Radio story

 Television advertisement

 Poster at school

 College guidance office/Placement office

 Department of Education

 High school guidance counselor

 Newspaper/Magazine article

 Peace Corps

 Radio advertisement

 Received information in the mail

 Television news story

 Other (specify) _______________________________________________

 I prefer not to provide my demographics information

What is your ethnicity? (optional)  Hispanic or Latino  Not Hispanic or Latino

What is your race? (optional) Mark one or more.

 American Indian or Alaska Native. 

A person having origins in any of the original peoples of North and South America (including Central America) and who maintains 

tribal affiliation or community attachment.

 Asian. 

A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, 

Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

 Black or African American. 

A person having origins in any of the black racial groups of Africa.

 Native Hawaiian or Other Pacific Islander. 

A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

 White.

A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

What is the highest level of education completed by your mother?

 Less than high school

 High school diploma or the equivalent, such as GED

 Some college but no degree

 Associate degree in college

 Bachelor’s degree

 Master’s, professional school, or doctoral degree

 Don’t know

 This question does not apply to me.

What is the highest level of education completed by your father?

 Less than high school

 High school diploma or the equivalent, such as GED

 Some college but no degree

 Associate degree in college

 Bachelor’s degree

 Master’s, professional school, or doctoral degree

 Don’t know

 This question does not apply to me.

Which category represents the total combined income of all members of your family during the past 12 months? This includes money or 

income received by members of your family who are 15 years of age or older.

 $24,999 or less

 $25,000 to $39,999

 $40,000 to $59,999

 $60,000 to $74,999

 $75,000 to $99,999

 $100,000 to $149,999

 $150,000 or more

 Don’t know

How confident are you that you could come up with $400 if an unexpected expense arose within the next month?

 Not at all confident

 Slightly confident

 Somewhat confident

 Very confident

 Extremely confident

 Don’t know
Page 11 of 11

WHERE TO SEND YOUR APPLICATION

Please send your application directly to the AmeriCorps program where you wish to serve. 

To get the address for the AmeriCorps program where you wish to serve, or to apply online, 

visit the AmeriCorps website at AmeriCorps.gov. If you don’t have Internet access, you can 

still get program information or apply by calling 1-800-942-2677.

Print out and use this application OR go to the My AmeriCorps Portal and apply online 

my.americorps.gov

If you are applying to AmeriCorps NCCC or FEMA Corps, send your application to: 

AmeriCorps NCCC

250 E Street SW

Washington, DC 20525