Form PC-2119 Peace Corps Response Volunteer Application

PCR Application Current OMB Control Number: 0420-0547

Current Expiration Date: 12/31/2014

Peace Corps Response Overview Thank you for your interest in applying to Peace Corps Response. Please review the following information before proceeding with this application.

The Peace Corps mission is to promote world peace and friendship by:

• Helping people of interested countries in meeting their need for trained men and women
• Helping promote a better understanding of Americans on the part of peoples served
• Helping promote a better understanding of other peoples on the part of Americans

Peace Corps Response assignments offer qualified Americans the opportunity to obtain considerable career experience, while aiming to accomplish tangible results and address the development needs of the host country in a short period of time. Assignments range from three months to one year in length.

Volunteers provide targeted assistance in diverse assignments covering a range of projects, including, among others, food security, civil engineering, information systems, library science, university level teaching, and global health.  Assignments can be both challenging and rewarding, requiring a full commitment to serve others. Peace Corps Response Volunteers should have experience in culturally diverse environments as well as the requisite technical expertise and language skills specified in the position description.

Eligibility Requirements

Should you be selected to serve as a Peace Corps Response Volunteer, you will be undertaking an exciting and life-changing experience. To be eligible to apply to Peace Corps Response, you must:

• be a U.S. citizen (non-citizens may apply but must have citizenship prior to serving); and

• be at least 18 years of age.

Are you a U.S. citizen (by birth or naturalization) and at least 18 years of age?

If no:

Thank you for your interest in serving with Peace Corps Response. The information you entered suggests you do not meet our eligibility requirements at this time. You must be a U.S. citizen and at least 18 years of age to serve.

If you are under 18, please continue your spirit of service and consider the two-year Peace Corps program or Peace Corps Response again when you are older. For more information regarding eligibility requirements for Peace Corps Response service, please consult the FAQs on our website.

Additional Eligibility Requirements

In addition to being a U.S. citizen and at least 18 years of age, Peace Corps Response Volunteers must have applicable experience.

Are you at least one of the following?

• a returned Peace Corps Volunteer;

• a professional with at least 10 years of experience; or

• a doctor or nurse applying to the Global Health Service Partnership (GHSP).

If no:

Thank you for your interest in serving with Peace Corps Response. The information you entered suggests you do not meet our eligibility requirements at this time.

We encourage you to consider applying to the two-year Peace Corps program or consider Peace Corps Response again in the future.

General Questions

How did you learn about Peace Corps Response?

Select One

Peace Corps Website

Email Marketing

LinkedIn

Peace Corps Social Media

COS Conference

Direct Mail

Magazine Advertisement

Conference/Career Event

Peace Corps Staff

Returned or Current Volunteer

Friends or Family

Seed Global Health

Other

If other, indicate here:

Contact Information

Please make sure this page contains your most up-to-date information so Peace Corps Response staff can contact you.

You must provide your full name as it appears on a legal document (e.g., passport, driver’s license, birth certificate, etc.).

Title (dropdown list Mr./Mrs./Miss./Ms./Dr., etc . . .)

First name (your legal/given name)

Full middle name (no initials)

Last name

Suffix (Jr., Sr., etc.)

Nickname (optional field)

Primary phone

Secondary phone

Permanent email address

The Peace Corps asks for your Social Security number because the Peace Corps Act, 22 U.S.C. 2519, requires us to do a background check on all Volunteers. The Peace Corps will also use it to ensure our records are accurate for tax and other financial accounting purposes.

Social Security number, including dashes (xxx-xx-xxxx)

Please re-enter your Social Security number, including dashes (xxx-xx-xxxx)

Sex (male/female)

Date of birth (day/month/year)

Current Address

Please ensure that you can collect mail in a timely manner from this address, as important mail and time-sensitive forms will be sent to this address.

Address line 1

Address line 2

Country

City

State/Region/Province

ZIP/Postal code

+4 (of ZIP code)

Permanent Address

For this section, please enter a permanent address where you can receive mail while overseas. This address should be in the U.S. If it is the same as the one above, please re-enter the address.

Address line 1

Address line 2

Country

City

State

ZIP/Postal code

+4 (of ZIP code)

Upload Your Resume

Please upload your résumé below. Your résumé should include all of your work history, volunteer experience, education, language skills, and cross-cultural experience. Some parts of your résumé will automatically populate fields of the application. Please review those fields and edit as necessary.

Résumé/CV

Choose one of the methods below to submit your résumé /CV.

Use a résumé /CV from my profile
Upload my résumé /CV from my computer

Education

What is the highest level of education you have achieved, or will have achieved prior to service? For example, if you are currently a second year Master’s student, but will have completed your degree prior to beginning your Peace Corps Response assignment, list the degree that you will be receiving as the highest level of education achieved.

Please provide the information below for all education institutions you attended or will graduate from prior to starting your service.

School name:

If school not listed, provide name here:

Type of degree, diploma, or certificate (single-select):

Date degree received or expected (mm/yyyy):

Major:

Employment History

Please review the completed fields to ensure that the information is accurate. Prior to moving on to the next page of your application, you will be required to select your “most recent” job.

Position or Job Title:

Organization Name:

Start year:

End year:

Most Recent:

Peace Corps Service History

Have you previously served with the Peace Corps or Peace Corps Response?

If yes:

What is your most recent Peace Corps/Peace Corps Response country of service?

What years did you serve there? (MM/YYYY to MM/YYYY)

If you have additional Peace Corps/Peace Corps Response service, please list the countries and dates below.

What years did you serve there? (MM/YYYY to MM/YYYY)

Relevant Experience and Skills

This section may auto-populate based upon answers that you have submitted with a previous application. Please verify that your answers address the qualifications to the position for which you are applying.

In one paragraph, please describe how your experience and skills meets the mandatory qualifications listed for this specific position. (2000 character limit)

Language Skills

Please list any language experience you have beginning with the language(s) that are most relevant for the position for which you are applying. Additionally, please indicate the level of proficiency for each language selected. If you do not see the language(s) you speak in the list provided, please select the “other” option at the bottom of the list, write in the language, and indicate your level of proficiency.

Language 1

Skill Level (Novice, Intermediate, Advanced, Superior)

Language 2

Skill Level (Novice, Intermediate, Advanced, Superior)

Language 3

Skill Level (Novice, Intermediate, Advanced, Superior)

Couples

Peace Corps Response will use its best efforts to accommodate requests by applicants to serve together as a married couple or in a domestic partnership. Please note that to place spouses/partners in the same location, projects must exist for both applicants that match their respective skill sets. Each spouse/partner will need to apply and qualify separately for assignments. If you are selected for an interview, a Peace Corps Response Recruiter will contact you and provide greater detail on your request to serve as a couple.

If you are applying to the Global Health Service Partnership, please refer to the FAQ regarding couples in this program.

Are you married or in a domestic partnership, or planning to be married or in a domestic partnership at the time you begin your service?

If yes, are you applying to serve with your spouse/domestic partner?

If yes, please list the name of your spouse/domestic partner:

First name

Middle name

Last name

Dependents

Dependents are not permitted to accompany serving Peace Corps Response Volunteers. In the event that an applicant with a dependent is selected for a Peace Corps Response position, the applicant must ensure that adequate arrangements have been made for the care and support of the dependent during service.

Are any persons partially or totally dependent upon you for support, whether or not they are living with you?

If yes, list all dependents and children under age 18.

Name of dependent

Relationship to dependent

Date of birth

Does the dependent live with you?

Military Status

Do you have any military, reserve, or National Guard obligations?

Arrests, Convictions and Other Legal Proceedings

The existence of an arrest or conviction record will not automatically exclude you from consideration for Peace Corps Response service. All Peace Corps Response invitees must undergo a background check that will disclose all arrests and convictions, regardless of whether the arrest or conviction has been expunged from your record.

It is your responsibility to inform the Peace Corps promptly throughout the application process of all new arrests, charges, citations, misdemeanors, and felonies (including ALL drug or alcohol-related legal incidents) and any other changes to the information provided below, including the disposition of existing offenses.

Have you ever been cited for, arrested, charged with, or convicted of any offense? Exclude minor traffic violations, citations, and parking tickets.

If yes:

Provide the applicable information below for the offense:

Type of offense (e.g., DUI, possession of marijuana, petty theft):

Date of incident:

Location of incident:

Was there a final court judgment?

Judgment date:

Current status or disposition:

List all penalties including sentence, probation, community service, fine, or other penalty imposed:

Explanation and detailed circumstances surrounding the offense:

Additional offense (if applicable):

Type of offense (e.g., DUI, possession of marijuana, petty theft):

Date of incident:

Location of incident:

Was there a final court judgment?

Judgment date:

Current status or disposition:

List all penalties including sentence, probation, community service, fine, or other penalty imposed:

Explanation and detailed circumstances surrounding the offense:

If you have additional offenses, please submit a statement that includes the information requested above as an attachment at the end of this application.

Are you on probation?

Are you currently involved in any court proceedings (civil or criminal) that will require your participation (as a plaintiff, defendant, or witness) during the time you would be serving as a Peace Corps Response Volunteer?

Intelligence Background The Peace Corps has a longstanding policy of excluding individuals who have engaged in intelligence activity or related work or who have been employed by or connected with an intelligence agency from Peace Corps Volunteer service, either for a specific period of time or permanently depending on the agency. For more information, including definitions of “intelligence activity” and “intelligence agency,” please go to www.peacecorps.gov/legalinfo.

If you are a current or former employee of the Central Intelligence Agency (CIA), you are permanently ineligible for Peace Corps Volunteer service. If you are currently or were formerly employed by another intelligence agency, you are ineligible for Peace Corps Volunteer service for at least 10 years from the end date of such employment.

In addition, you may be disqualified for service because your background or history discloses a substantial connection with an intelligence activity or related work other than through employment. Even family relationships to an employee of an intelligence agency may be considered a disqualifying connection. The duration of any such disqualification will ordinarily not exceed 10 years and will depend on the nature of your involvement in or relationship to intelligence activities or agencies.

You should also be aware that, if you serve as a Peace Corps Volunteer, you may be ineligible for employment with U.S. government intelligence agencies for a specified period following your service as a Volunteer.

If you or a family member works for or has worked for the CIA or the National Security Agency, go to www.peacecorps.gov/legalinfo for further instructions before answering the question below.

In all other cases, if you indicate that either you or a family member has been employed by or connected with an intelligence agency, or engaged in intelligence activity or related work, a Peace Corps representative will contact you after your application is submitted to obtain additional information and determine your eligibility for Peace Corps Volunteer service.

Based upon the preceding, please answer the following question:

Have you or a family member ever been employed by or connected with an intelligence agency, or engaged in intelligence activity or related work?

Request for Racial and Ethnic Data (Optional)

This information is voluntary. Your response will not affect consideration of your application. By providing this information, you will assist in assuring that the Peace Corps is administered in a nondiscriminatory manner and reflects the diversity of the United States. The information requested in this section is covered by the Privacy Act Notice.

Ethnicity

Please check one of the classifications in the Ethnicity section below.

Hispanic or Latino (a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. The term, "Spanish" origin can be used in addition to "Hispanic" or "Latino").

Not Hispanic or Latino

Race

Please check one or more of the classifications in the Race section below.

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)

Privacy Act

The Peace Corps, an agency of the federal government, is required by the Privacy Act of 1974 (5 U.S.C. 552a) to advise you of the following information regarding this application. The Privacy Act addresses the federal government’s use of certain personal information in agency files.

A. This application is authorized by the Peace Corps Act (22 U.S.C. 2501 et seq.) as amended.

B. The information you provide will be used is to evaluate your suitability and qualifications to serve as a Peace Corps Volunteer.

C. This information may be used for the routine uses described in the Privacy Act, 5 U.S.C. 552a, and the Peace Corps' published Routine Uses, summarized in Peace Corps' System of Records.

D. The completion of this application is voluntary. However, failure to complete the application will result in the Peace Corps being unable to assess your qualifications and may preclude your consideration for the Peace Corps.

E. The Peace Corps asks for your Social Security number because the Peace Corps Act, 22 U.S.C. 2519, requires us to do a background check on all Volunteers. The Peace Corps will also use it to ensure our records are accurate for tax and other financial accounting purposes.

PLEASE NOTE: The Peace Corps does not discriminate based on race, color, religion, sex, national origin, age (over 40), disability, sexual orientation, gender identity, gender expression, marital status, parental status, political affiliation, union membership, genetic information, or history of participation in the EEO process, any grievance procedure or any authorized complaint procedure. Anyone who feels he or she has been discriminated against should contact the Office of Civil Rights and Diversity, 202.692.2139, [email protected], 1111 20th Street NW, Washington, DC 20526.

Paperwork Reduction Act Burden Statement

Public reporting burden for this information collection is estimated to average 1 hour. This includes the time for reviewing instructions and completing the information. This is voluntary information collection. An agency may not conduct or sponsor, and persons are 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, 2nd Floor, Washington, D.C. 20526.

Certification

I certify that all of the statements made on all pages of this application, including attachments, are true, correct, and complete to the best of my knowledge and are made in good faith. I understand that any misleading, inaccurate, or incomplete information may be cause for disqualification or termination from Peace Corps service. In addition, any intentionally false statement or intended omission may be subject to fines and/or imprisonment pursuant to 18 U.S.C. 1001.

I also understand it is my responsibility throughout the application process to inform the Peace Corps promptly of any changes to the information provided here.

For Peace Corps Response applicants applying to Global Health Service Partnership assignments, I authorize the Peace Corps to disclose the information in my application to Seed Global Health for the purposes of evaluating my qualifications.

Signature

Date

Application Review

Please verify that the information in your application is correct by using the “Preview” link below. To make edits to the application itself, please use the “Previous” button at the bottom of this page (do not press the back button). Once your application is final, click the “Submit” button to complete the application.

Failure to provide correct information in the following fields can significantly delay your application process:

• Name as it appears on a legal document (passport, driver's license, birth certificate, etc.)

• Social Security number

• Date of birth

• Sex

• Email address

• Current address

Thank you for your interest in serving as a Peace Corps Response Volunteer. We look forward to reviewing your application.

We invite you to continue searching for positions that match your interests as you may submit multiple Peace Corps Response applications.

In addition, connect with us on Facebook or sign-up for our monthly newsletter for the most up-to-date vacancy announcements, online information sessions, and exciting stories of volunteer service!

PC-2119