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Peace Corps 50 th Anniversary Archive
Thank you for contributing to the Peace Corps 50 th Anniversary Archive Project.
Many of the stories and photos submitted to the archive will be used to honor and
celebrate our legacy of service during Peace Corps' 50th anniversary celebration in
2011, and the 50 th Anniversary Archive collection will be maintained as part of the Peace
Corps' permanent archives. Archive materials will be accessible to the pUblic through
the Peace Corps website, and will be shared with the National Archives and Records
Administration (NARA).
We are accepting only one story and up to 5 photos per contributor.
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Contributors must also complete the accompanying Peace Corps sd Anniversary
Archive Project Material Submission Authorization and Agreement and return it along
with your submissions. Contributors must accept the terms of the agreement in order to
submit items to the archive.
Please return your
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to:
Your story and/or photo(s)
Your completed submission form
Your completed Peace Corps sdh Anniversary Archive Project Material
Submission Authorization and Agreement
Peace Corps
Office of Communications
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50 Anniversary Archive Project
1111 20 th Street, NW
Washington, DC 20526
PC-841 (06/2008)
50th ANNVERSARY ARCHIVE PROJECT
SUBMISSION FORM
Contributor Information
Name:
Address:
Telephone:
E-mail:
Relationship to Peace Corps Volunteer:
Peace Corps Volunteer Information
First Name:
Middle Name:
Last Name:
Country of Service:
Service Years
to
Sector of Service:
(select one)
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Agriculture
Business Development
Community Development
Education
Environment
Health
HIV/AIDS
Information Technology
Youth Development
PC-841 (06/2008)
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Archive Items
Please fill in the appropriate sections for the materials you are submitting.
_ I am sUbmitting a story only (stories should be no more than 1500 words)
_, am submitting photos only (up to 5 photos)
_ I am submitting a story and photos
Story
Story Title:
Photo 1
Photo Title:
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(do not exceed 80 characters)
Photo subject(s): (check all that apply)
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Host Family
Host Community Friends
Celebrations/Special Occasion
Work
Food/Meals
Housing
Transportation
Other
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PLEASE DESCRIBE ITEM: Please provide as much detail as you can-where and
r n was it taken, who is in the photo, What is ha~pening in the ~hoto, etc...
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Photo 2
Photo Title:
Photo subject(s): (check all that apply)
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Host Family
Host Community Friends
Celebrations/Special Occasion
Work
Food/Meals
PC-841 (06/2008)
(do not exceed 80 characters)
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_
Housing
Transportation
Other
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PLEASE DESCRIBE ITEM: Please provide as much detail as you can-where and
when was it taken, who is in the photo, what is happening in the photo, etc...
Photo 3
Photo Title:
(do not exceed 80 characters)
Photo subject(s): (check all that apply)
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_
_
_
_
Host Family
Host Community Friends
Celebrations/Special Occasion
Work
Food/Meals
Housing
Transportation
Other
_
PLEASE DESCRIBE ITEM: Please provide as much detail as you can-where and
when was it taken, who is in the photo, what is happening in the photo, etc...
PC-841 (06/2008)
Photo 4
Photo Title:
(do not exceed 80 characters)
Photo subject(s): (check all that apply)
_
_
_
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_
Host Family
Host Community Friends
Celebrations/Special Occasion
Work
Food/Meals
Housing
Transportation
Other
_
PLEASE DESCRIBE ITEM: Please provide as much detail as you can-where and
when was it taken, who is Ln ~he hoto, what is ha enin in the hoto, etc...
Photo 5
Photo Title:
(do not exceed 80 characters)
P!'loto subject(s): (check all that apply)
_
_
_
_
_
Host Family
Host Community Friends
Celebrations/Special Occasion
Work
Food/Meals
Housing
Transportation
Other
_
PLEASE DESCRIBE ITEM: Please provide as much detail as you can-where and
when was it taken, who is in the hoto, what is ha enin in the hoto, etc...
PC-841 (06/2008)
PRIVACY ACT NOTICE: This notice is provided under the Privacy Act of 1974, as amended (5
U.S.C. §552a). The information requested is collected under the authority of the Peace Corps
Act, 22 U.S.C. §2501 et seq., for the purpose of gathering material in relation to the Peace Corps'
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50 Anniversary. The information may also be used for routine uses listed in the System of
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Records Notice PC-31, Peace Corps 50 Anniversary Archive, which, upon approval, will be
available in our electronic reading room at http://www.peacecorps.gov. Providing the material
herein is completely voluntary, however failure to disclose sufficient information may result in
submissions not being retained.
Paperwork Reduction Act Burden paragraph per 5 CFR Part 1320(b)(3): This is a voluntary
information collection. The estimated burden for completing this form is 15 minutes. You are not
required to respond to any collection of information unless it displays a currently valid OMB
appiOval number. Comments on the burden should be sent to: the director of the Peace Corps
Office of Communications, 1111 20th Street, NW, 2nd Floor, Washington, D.C. 20526 and to the
Office of Management and BUdget, New Executive Office Building, Room 10202, Washington,
D.C. 20503.
PC-841 (06/2008)
| File Type | application/pdf |
| File Modified | 2008-08-08 |
| File Created | 2008-08-08 |