National Service Trust Enrollment Form

Completion of this form is required to enroll a serving member in the National Service Trust, making 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. 

PART 1 Member: Please Complete and Sign

1. Name

Last First MI

2. Date of Birth 3. Social Security Number

Month Day Year

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 I551; (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 eligibility to enroll in an AmeriCorps program.

*** You are an asylee if you have a Form I-94 with asylum granted stamp; form I-766 with Category “A5”, “A05”, 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 have not completed a high school diploma or its equivalent:

I agree to obtain a high school diploma or its equivalent before using my educational award, and I did not 

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

If you have some college:

Choose the most recent school you attended

Choose One

If school is not listed, provide name here 

Type of degree, diploma, or certificate Choose One

If you have an Associate’s degree:

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

Choose One

If school is not listed, provide name here 

Type of degree, diploma, or certificate Choose On

If you have a Bachelor’s degree:

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

Choose One
If school is not listed, provide name here 

Type of degree, diploma, or certificate Choose One

If you have a graduate degree:

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

Choose One

If school is not listed, provide name here 

Type of degree, diploma, or certificate Choose One

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 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. § 1001, 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. §§ 3801-3812.

Member’s Signature Date
PART 3 Member: Please Answer the Following Questions

CNCS gathers information about sex, race, ethnicity, and disability status to ensure opportunities are provided to 

serve for people of all conditions. This information will solely be used for data analysis. The information you provide 

will not be used in any way to determine or affect any federal benefit. Providing this information is optional. If you do 

not wish to answer, please check “Prefer not to respond.” We sincerely hope that you will answer these questions to 

assist us in analyzing our ability to serve all Americans equally.

1. What is your sex?

Female Male

2. Are you registered to vote?

Yes No

Not sure Not eligible Prefer not to respond

4. 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

Prefer not to respond

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

Hispanic or Latina/o Not Hispanic or Latina/o Prefer not to respond

6. 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

Prefer not to respond

7. What is your best estimate of your household’s income for the past 12 months?

Under $10,000

$10,000 to $19,999

$20,000 to $29,999

$30,000 to $39,999

$40,000 to $49,999

$50,000 to $59,999

$60,000 to $69,999

$70,000 to $79,999

$80,000 to $89,999

$90,000 to $99,999

$100,000 or more

Prefer not to respond

8. Do you receive Social Security disability benefits, such as Supplemental Security Income (SSI) or Social Security Disability

Insurance (SSDI)?

Yes No Prefer not to respond

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

o Recruitment brochure

o College Resource Fair

o Facebook ad or on Facebook in general

o Twitter

o Other social media platform. Please specify: 

_____________________

o AmeriCorps online recruitment system

o Job search Web page

o Article (online, newspaper, or magazine)

o Advertisement in a newspaper/magazine

o Guidance counselor/teacher

o Parent/relative

o Current or former AmeriCorps Member

o Friend

o TV commercial

o Radio commercial

o AmeriCorps recruiter/representative

o Received information in the mail

o AmeriCorps program poster

o Other. Please 

specify: 
For Official Use Only

For Official Use Only

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, 1201 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 

1320.5(b)(2)(1))

Privacy Statement -- In compliance with the Privacy Act of 1974, the following information is provided: The collection of this information is authorized by the provisions of the National 

and Community Service Act of 1990, as amended. 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. In furtherance of CNCS’s efforts to 

ensure that the programs are inclusive of persons with disabilities, your Social Security Number may be released to the Social Security Administration to measure aggregate statistical 

data on the number of AmeriCorps members receiving disability-based benefits. Information may also be provided to federal, state, and local agencies for law enforcement purposes. 

The Internal Revenue Service has determined that the education award is taxable in the year it is used. Your Social Security Number (SSN) is solicited under the authority of the Internal 

revenue Code (26 U.S.C. 6011(b) and 6109) for use as a taxpayer identification number. Failure to disclose the 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. 

OMB Approval No.: 3045-0006
For Official Use Only

For Official Use Only

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 (1700 hours per year, or 365 days per year for VISTA)

VISTA Summer Associate (10-12 weeks)

Half-time (900 hours in no more than 2 years)

Half-time (900 hours in no more than 1 year)

Reduced half-time 675 hours

Quarter time 450 hours

Minimum time/Summer 300 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

Number and Street

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 1001of 

Title 18. U.S.C or other actions authorized by the Civil Fraud Remedies Act, 31 USC 3801-3812. 

Signature of Certifying Official Date

Name of Certifying Official (Please Print):