Form PC-1502 Peace Corps Volunteer Application

PCV Application - February 2014

OMB Control Number: 0420-0005

Expiration Date: xx/xx/20xx

General Instructions

Thank you for your interest in serving as a Peace Corps Volunteer. Should you become a Peace Corps Volunteer, you will be undertaking an exciting and life-changing experience. To be eligible to serve in the Peace Corps, you must

• be a citizen of the United States (non-citizens may apply but must have citizenship prior to serving);

• be at least 18 years of age; and

• meet the medical, legal, and security requirements.

Citizenship

Are you a U.S. citizen (by birth or naturalization), or do you expect to become a naturalized citizen in the next 12 months?

If you are in the process of becoming a naturalized citizen, please provide your estimated date of naturalization. For additional information on required legal documentation, visit www.peacecorps.gov/legalinfo.

Age Requirement

Are you at least 18 years of age?

Contact Information

You must provide your full legal name as it appears on a legal document (e.g., passport, driver’s license, birth certificate, etc.). Please inform the Peace Corps immediately if your contact information changes.

First name (your legal/given name)

Middle name (not initial)

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

Please reenter your Social Security number including dashes (xxx-xx-xxxx).

Gender (male/female)

Date of birth (day, month, year)

Current Physical/Mailing Address

You must be able to collect mail from this address in a timely manner.

Address line 1

Address line 2

Country

County (CA residents only)

City

State/Region/Province

ZIP/Postal code

+4 (of ZIP code)

Permanent Address

For this section, please enter a secondary address where you can also receive mail. This address should be in the U.S.

Address line 1

Address line 2

Country

County (CA residents only)

City

State

ZIP/Postal code

+4 (of ZIP code)

Date of Availability

What is the earliest date you can be available for Peace Corps service? You will be considered for assignments beginning after this date.

Upload Your Résumé

Please upload your résumé below. Your résumé should include all of your work history, volunteer experience, education, language skills, and cross-cultural experience. An example of a résumé including the necessary information can be found here.

Some parts of your résumé will automatically populate fields of the application. Please review those fields and edit as necessary.

Previous Peace Corps History

Have you ever applied to be a Peace Corps Volunteer?

Have you ever served as a Peace Corps Volunteer?

Have you ever served as a Peace Corps Response Volunteer?

Couples

The Peace Corps makes efforts to place married couples and domestic partners who wish to serve together. Please be aware that the opportunities to place couples are more limited than those for individual candidates, so the application process may take longer. In order to serve together, both you and your spouse/ domestic partner must apply at the same time and qualify for assignments in the same country.

• 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 planning to serve with your spouse or domestic partner?

First name of spouse/ domestic partner

Middle name of spouse/ domestic partner

Last name of spouse/ domestic partner

For additional information on serving as a couple and the required legal documentation, visit www.peacecorps.gov/legalinfo.

Dependents

Serving as a Peace Corps Volunteer with dependents at home or elsewhere is often a challenge. Are any persons partially or totally dependent upon you for support, whether or not they are living with you? Yes/No

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

Name of dependent

Relationship to dependent

Does the dependent live with you?

Date of birth if 18 or under?

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 service. When evaluating an arrest or conviction, the Peace Corps considers the nature of the offense, how long ago the offense occurred, whether you were acquitted of the offense, and other relevant facts or indications of rehabilitation. If you are ultimately rejected for a Peace Corps Volunteer position because of an arrest or conviction in your background, you will have the opportunity to appeal the decision and/or reapply at a later date.

All Peace Corps 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. For more information about the background check and policies on arrests and convictions, go to www.peacecorps.gov/legalinfo.

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. Do not include minor traffic violations, citations, or parking tickets.

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

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? For additional information on what constitutes probation, visit www.peacecorps.gov/legalinfo.

• 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 Volunteer?

Intelligence Background

The Peace Corps has a longstanding policy 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?

Education

What is the highest level of education you have achieved, or will have achieved prior to service? For example, if you are applying as a senior in college and will have completed your degree prior to beginning your Peace Corps service, list the degree that you will be receiving as the highest level of education achieved.

Please provide the information listed below for all education institutions you attended or will graduate from prior to leaving for 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:

GPA:

Certificate

• Are you or will you be a state-certified teacher? (Yes/No)

  • If yes, please provide teacher certification information below.

State:

Subject:

Grade level:

Issuance date:

Master’s International

The Master's International program offers a unique opportunity to combine Peace Corps service with a master's degree program. Prospective students apply separately to the Peace Corps and to a participating graduate school. Once accepted by both, students will study on campus, usually for one year, and then spend the next two years earning academic credit while working overseas in a related Peace Corps project. Depending on the program, there may be additional incentives for Master’s International students while on campus. For more information about Master's International, visit www.peacecorps.gov/gradschool.

• Are you applying to the Peace Corps as a Master’s International candidate? Yes/No

  • If yes, please select school and program.

  • What is the degree you are seeking through the Master’s International program?

Peace Corps Prep

Students apply to Peace Corps Prep through participating undergraduate institutions typically during their sophomore or junior year of college. Through the program, students take select coursework, including foreign language studies, and engage in a hands-on service-learning or internship experience.

• Are you currently or have you previously participated in Peace Corps Prep? (Yes/No)

  • If yes, please select the Peace Corps Prep school from the list:

Language Skills
In the countries where the Peace Corps serves, many languages are spoken, including French and Spanish. To be considered for a French- or Spanish-speaking country, prior experience with that language is required.

Please list any languages you have experience with, beginning with the language(s) that are most relevant for the position for which you are applying. Additionally, please indicate the level of verbal 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 verbal proficiency.

Language 1:

Skill level:

If Other, please indicate language:

Language 2:

Skill level:

If Other, please indicate language:

Language 3:

Skill level:

If Other, please indicate language:

Motivation Statement

Peace Corps service presents major physical, emotional, and intellectual challenges. In the space below, please provide a statement explaining your reasons for wanting to serve as a Peace Corps Volunteer and how you plan to overcome the various challenges associated with Peace Corps service (less than 500 words).

References

The Peace Corps requires two references. The Peace Corps will not contact your references unless you are selected to interview for a position. Recommendations must be from the following individuals:

• A close friend who has known you for at least two years (the person cannot be related to you)

and
• A current or previous employment supervisor,
• A current or previous volunteer work supervisor, or

• A professor

Reference – Close Friend Reference

Reference type (close friend reference):

Reference name (first and last name):

Reference email address:

Reference telephone (optional):

Reference – Job/Volunteer Supervisor or Professor

Reference type (job supervisor, professor):

Reference name (first and last name):

Reference email address:

Reference telephone (optional):

Reference – RPCVs only (if served in the last five years)

Returned Peace Corps Volunteers who completed service in the last five years are required to submit an additional reference from a Peace Corps staff person from their country of service.

• Are you a Returned Peace Corps Volunteer who completed service within the past five years? Yes/No

If yes, complete staff reference information below.

Peace Corps Staff Reference

Reference name (first and last name):

Country of service:

Reference email address:

Request for Racial and Ethnic Data

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)

[Confirmation]

Privacy Act Statement

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.

Paperwork Reduction Act Notice:  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: the FOIA Officer, Peace Corps, 1111 20^th Street NW, 2^nd Floor, Washington, D.C. 20526 or [email protected].

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.

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.

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 you are confident that your application is final, click the “Submit” button to complete the application process.

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

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

• Social Security number

• Date of birth

• Gender

• Email address

• Current address

Thank you for applying to the Peace Corps.

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