PC-1835c Staff Video Submission

OMB No. 0420-xxxx
Expiration Date: xx/xx/20xx

Staff Video Submission
Thank you for your interest in contributing to the Peace Corps Digital Library. Your contribution will
help ensure that the Peace Corps’ rich legacy of service is maintained for future generations.
This is also the staff submission form for the Peace Corps AIDS-Free Generation Video
Contest.
Are you contributing a video that reflects your time as a Peace Corps Volunteer? Please submit it to
our Volunteer collection
» Volunteer Video Submission

Video Submission Guidelines
In order to be published in the digital library, your submission must:

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Be sensitive to the privacy concerns of individuals, including host country nationals;
Not malign the Peace Corps, or any other group or individual;
Not include inflammatory, rude or offensive language or content;
Not include links to or URLs for Internet sites;
Not be used to promote products or services;
Not include any personal identifying information such as Social Security numbers, phone numbers,
email addresses or street addresses
Note: fields with an asterisk (*) are required.

Add Video
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* Video Title

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* Video Description
Please provide as much detail as you can - where and when the video was taken, who is in the video,
what is happening.

[e.g. I took this video during the first day of school celebrations on Sept. 1, 1994, at School #97 in
Kanaganda, Kazakhstan. The first day of school is a major holiday in Kazakhstan. The video shows two
primary school girls handing flowers to their new teacher in the school auditorium while parents,
students and teachers look on.]
Burden Statement:
Public reporting burden for this collection of information is estimated to average 15 minutes per response. 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 information, including suggestions for reducing this burden, to: FOIA Officer, Peace Corps, 1111 20th
Street, NW, Washington, DC 20526 ATTN: PRA (0420-####). Do not return the completed form to this address.
PC-1835c (rev. 1/2013)

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* Country
Country Where Photo Was Taken

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* Video Date
Year

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* Upload Video
DO NOT include spaces or special
characters (&, #, !, ?) in filenames.

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My submission adheres to the video submission guidelines outlined above Please verify you read
the video submission guidelines

Contact Information
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* First Name

Middle Name

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* Last Name

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* City

* State

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* Country

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* Email

* Re-type Email

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* Telephone
(xxx-xxx-xxxx)

Was your name different at the time of your Peace Corps employment?

Yes

No

About Your Employment
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* Country
Country of Employment

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* Employment Dates
Begin

End

Did you work for Peace Corps for an additional tour?

Yes

No

About the Digital Library Project
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May a Peace Corps staff member contact you if we have questions about your submission?
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Yes
No Please indicate if a Peace Corps staff member may contact you about your
submission
We anticipate great interest in the 50th anniversary among the domestic and international press,
partner universities, RPCV groups and other organizations such as libraries and museums. May we
provide your contact information (email and telephone) to groups interested in contacting you for
interviews, exhibits, etc? [Note: Peace Corps does not release contact information to groups for the
purpose of fundraising.]
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Yes
No Please indicate if we may provide your contact information to groups interested in
contacting you for 50th Anniversary activities
We are working to establish a permanent home for original, primary source archival materials about
the Peace Corps experience [Ex. letters, journals, Volunteer newsletters or cookbooks from your
country of service, videos, slides, video or audio recordings taken while in service, artwork or artifacts,
etc…]. May we contact you at a future date about contributing your original materials?

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Yes
No Please indicate if we may contact you at a future date about contributing your
original materials
If yes, please describe the original materials you have:

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Authorization and Agreement
full description below

I, on behalf of myself, heirs and assigns, do represent and agree to the following:
1). I am the lawful copyright or intellectual property right holder of the material submitted under this Authorization
and Agreement which permits me to provide this material to the Peace Corps under this Authorization and
Agreement .
2). I forever grant the Peace Corps a perpetual, worldwide, royalty-free, non-exclusive license in and right to sublicense the materials submitted, and authorize the Peace Corps to make any use of this material. It is my intention
to give the Peace Corps the right to disseminate, reproduce, publish, publicize and make any uses of the materials
submitted under this Authorization and Agreement, for any purposes whatsoever, through any forum or media
possible. By submitting this material, it is my intention to provide the Peace Corps with the maximum reproduction,
dissemination, publication, and all other possible usage rights possible by law.
I understand that the Peace Corps may attribute my submission to me, and I hereby authorize the Peace Corps to
make any reference to me in regard to these materials. By submitting material to the Peace Corps under this
Authorization and Agreement, I understand and agree that this material will be subject to public disclosure under
the Freedom of Information Act, may be made accessible to the public by the Peace Corps, and may be submitted
to the National Archives and Records Administration and therefore publicly accessible.
3). I understand that the Peace Corps reserves the right to accept, reject or edit all submissions in whole or in part.
Any submission under this Authorization and Agreement, if accepted by the Peace Corps under the terms of this
Agreement, may be used, maintained or disposed of in the sole discretion of the Peace Corps. I acknowledge that
regardless of whether the submission is accepted or rejected by the Peace Corps, it may not be returned to me.
4). I acknowledge that I will receive no financial compensation from the Peace Corps in consideration of my
agreement to this Authorization and Agreement , or in regard to my provision of the above listed submissions.
5). My submission of this Authorization and Agreement and affirmative indication of acceptance of the terms of this
Authorization and Agreement, through any physical, electronic, fax, or other means serves as my legally valid
signature to this Authorization and Agreement, and has the full force and effect of my original written signature.

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I accept the terms of the Peace Corps Material Submission Authorization and Agreement. Please
verify you read the authorization agreement

Submit

If you are experiencing difficulties submitting your materials, please email [email protected] to
notify the system administrator.