Form PC-909.5 1a PC-909.5 1a Hometown News Release Form

OMB control no.: 0420-xxxx
Expiration date: xx/xx/xxxx

Hometown News Release
Information for the Media
Completing the form is optional, but we encourage you to answer each question thoroughly
so that we can share accurate information with the media. Please be sure to sign and date the
form. Please list your hometown (or nearest city) newspapers or other publications in any
format that you would like included in any distribution of this release. Don't forget about your
college or university newspapers! In addition to the publications you list, the Peace Corps may
release and publish the information contained in this form to any publication it deems
appropriate.
Peace Corps' Press Office
Phone: 202.692.2230
[email protected]
Send photo submissions to: [email protected]
Please save the photo with your last name, country of service and departure date. For
example: Smith_Morocco_6.12.2012.jpg

Name:
Date of Birth: Hometown:
Hometown Zip Code:
Current City of Residence:
Current City Zip Code:

Current contact information:
Email Address:
Home Phone Number:
Cell phone number:
Burden Statement:
Public reporting burden for this collection of information is estimated to average 9 minutes. This estimate includes
the time for reviewing instructions and completing the collection of information. An agency may not conduct or
sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid
OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of
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information, including suggestions for reducing this burden, to: FOIA Officer, Peace Corps, 1111 20 Street, NW,
Washington, DC 20526 ATTN: PRA (0420-####). Do not return the completed form to this address.
PC-909.5 1a (Rev. 02/2013)

Publication Name City,
State
Publication Name City,
State
Country of Service:
Estimated Departure Date:
Peace Corps Assignment Name:
Brief Description of Your Work:

Parent, Guardian or Children's Names:

Where do they live?
Please note if any of your family members served as Peace Corps volunteers:

Name of Secondary School:
City, State:
Please list noteworthy high school or hometown activities to list:
Undergraduate College or University:
City, State:
Degree Title and Year:
How did your college/university prepare you or lead you to Peace Corps?

Graduate University:
City, State:
Degree Title and Year:
Please list your previous work experience:

What motivated or attracted you to join the Peace Corps?

What personal or professional goals do you hope to achieve during your Peace Corps service?

Would you like us to include any other information?

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 purposes of preparing news reports and other
public information for the Peace Corps. This information may also be used for the routine uses
described in the Privacy Act, 5 U.S.C. §552a, and in the Federal Register at 65 Fed. Reg.
53,722 (September 5, 2000) and 50 Fed. Reg. 1950, 1962 (January 14, 1985) regarding Peace
Corps systems of records pc-17 (Volunteer Records). Providing the material herein is
completely voluntary, but failure to authorize the release of this information will make it
impossible to provide press releases and other public information regarding your background
before you became a Volunteer and your activities while in service.
Your signature hereby authorizes the release and publication of any and all information
contained herein unless revoked in writing.

Signature:

Date: