Form 1 2014 AC Enrollment Form

National Service Trust Enrollment Form

Completing this form enrolls an AmeriCorps member in the National Service Trust, which makes the member eligible for a Segal AmeriCorps Education Award upon successful completion of his or her term of service. It also provides the Corporation for National and Community Service (CNCS) with basic demographic data. This form may be filled out on paper or electronically.

PART 1

Member: Please Complete and Sign

1. Name Last First MI

2. Date of Birth Month Day Year

3. Social Security Number

4. Citizenship Status

I am a U.S. Citizen or National *

I am a Lawful Permanent Resident Alien of the United States **

I am an Asylee ***

*Citizens of the US include persons born in Puerto Rico, Guam, the US Virgin Islands, and the Northern Mariana Islands. Nationals of the US include persons born in America Samoa, including Swains Island.

**Generally, you are a Lawful Permanent Resident Alien of the US if you are a US permanent resident with (i) a Permanent Resident Card, USCIS Form I-551; (ii) an Alien Registration Receipt Card, USCIS Form I-551, (iii) a passport indicating that the USCIS has approved it as temporary evidence of lawful admission for permanent residence; or (iv) a form I-94 indicating that the USCIS has approved it as temporary evidence of lawful admission for permanent residence. NOTE: A student visa does not confer resident status.

*** You are an asylee if you have a Form I-94 with asylum granted stamp; form I-766 with Category “A5”, “A5”, or “A-5”; or an Order of the Immigration Judge granting asylum.

5. School Status

What is the highest level of education you have completed?

Less than high school

High school diploma/GED

Technical school/apprenticeship/vocational

Some college

Associates degree (AA)

College graduate

Graduate degree (e.g. MA, PhD, MD, JD)

If you do not have a high school diploma or its equivalent:

I agree to obtain a high school diploma or its equivalent, and I did not drop out of elementary school or secondary school to enroll in the program.

I am exempt from the requirement to have a high school diploma, due to:

If you have some college:

Choose the most recent school you attended

If school is not listed, provide name here

Type of degree, diploma, or certificate

If you have an Associate’s degree:

Choose the school from which you received your most recent Associate’s degree

If school is not listed, provide name here

Type of degree, diploma, or certificate

If you have a Bachelor’s degree:

Choose the school from which you received your most recent Bachelor’s degree

If school is not listed, provide name here

Type of degree, diploma, or certificate

If you have a graduate degree:

Choose the school from which you received your most recent graduate degree

If school is not listed, provide name here

Type of degree, diploma, or certificate

6. Current Address (All information will be sent to you at this address until you notify CNCS of a change of address.)

Number and Street

City

State

Zip Code

Email Address

Home Phone

Business Phone

Ext

7. Permanent Address (Name and address of person through whom you can always be reached once you leave the program.) Check here if same as current address.

Last

First

MI

Number and Street

City

State

Zip Code

Email Address

Home Phone

Business Phone

Ext

8. Have you previously enrolled in an AmeriCorps, Silver Scholar, or Serve America Fellow Program? No Yes How many times?

9. Have you ever been terminated/released for cause by any AmeriCorps, Silver Scholar, or Serve America Fellow program? No Yes

10. Segal Education Award Limitations. I understand that I may not receive more than the aggregate value of two full-time Segal Education Awards and that upon successful completion of the term of service, I will receive only that portion of the Segal Education Award for which I am eligible, which may be all or a part of aSegalEducationAward, or no Segal Education Award, pursuant to 45 CFR § 2526.55.

PART 2

Member Enrollment Certification

By signing this enrollment form I agree, if asked, to provide documentation to verify the accuracy of the information I have provided in this form. I understand that a knowing and willful false statement on this form can be punished by one or more of the following: a fine or imprisonment or both under 18 U.S.C. § 11, exclusion from participation in federal programs, and forfeiture of benefits I may receive as a result of my enrollment or other actions authorized by the Civil Fraud Remedies Act, 31 U.S.C. §§ 381-3812.

Member’s Signature

Date

PART 3

Member: Please Answer the Following Questions

CNCS gathers information about sex, race, ethnicity, and other demographic information to ensure the agency has the most complete and inclusive data on national service participants. This information is confidential, and will solely be used for data analysis to assist us in ensuring we serve all Americans equally. The information you provide will

not be used in any way to determine or affect any federal benefit. Your responses are required in order to be enrolled as an AmeriCorps member, but will be kept confidential.

1. What is your sex?

Female Male

2. Are you registered to vote?

Yes No

Not sure Not eligible

3. Which of the following categories best describes your racial origin? (check all that apply)

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

Black or African American

White

Asian American

Other

4. Which of the following categories best describes your ethnic origin?

Hispanic or Latina/o Not Hispanic or Latina/o

5. What is your military, veteran, or family member status? (check all that apply)

Note: All honorably discharged veterans qualify for nomination for the Presidents Volunteer Service Award.

I am a Veteran

I am an Active Duty Member of the U.S. Armed Forces

I am a Member of the National Guard or Reserve Component

I am an immediate family member of a Veteran

I am an immediate family member of an Active Duty Member of the U.S. Armed Forces

I am an immediate family member of a National Guard Member or Reservist

I am not in the military, a veteran or a family member of someone in the US. Armed Forces

6. How did you hear about this program? (check all that apply.)

Recruitment brochure

College Resource Fair

Facebook ad or on Facebook in general

Twitter

Other social media platform. Please specify:

AmeriCorps online recruitment system

Job search web page

Article (online, newspaper, or magazine)

Advertisement in a newspaper/magazine

Guidance counselor/teacher

Parent/relative

Current or former AmeriCorps member

Friend

TV commercial

Radio commercial

AmeriCorps recruiter/representative

Received information in the mail

AmeriCorps program poster

State Service Commission

Other. Please specify:

PUBLIC BURDEN STATEMENT: Public reporting burden for this collection of information is estimated to average 10 minutes per submission, including reviewing instructions, gathering and maintaining the data needed, and completing the form. Comments on the burden or content of this instrument may be sent to the Corporation for National and Community Service, Attn: Amy Borgstrom, 1201 New York Avenue, NW, Washington, D.C. 20525. The Corporation informs people who may respond to this collection of information that they are not required to respond to the collection of information unless the OMB control number and expiration date displayed on page 1 are current and valid. (See 5 C.F.R. 1320.5(b)(2)(i).)

In compliance with the Privacy Act of 1974, the following information is provided: The information requested on the AmeriCorps Exit Form is collected pursuant to 42 U.S.C. §§ 12573 and 12602 of the National and Community Service Act of 1990, as amended.  The primary purpose of the information is to successfully exit a member from a term of service and enable him or her to receive the education award.The evaluative information will help CNCS improve its programming and services to members. Information may be shared with other agencies, such as the Social Security Administration, through computer matching agreements for the purpose of verifying identity and citizenship status information provided by you in this document, as well as other matching and data sharing agreements with federal agencies, agency contractors, and other non-federal entities to assist the agency in its research and statistical evaluation missions. Your Social Security Number (SSN) is solicited under the authority of the Internal Revenue Code (26 U.S.C. 6011(b) and 6109) for use as a taxpayer identification number. While disclosure of your SSN is voluntary, failure to disclose your SSN may result in a denial of your receiving an education award.  All information obtained will be used only for official purposes, treated confidentially, and will not be disclosed outside the agency unless there is a specific official need for the recipient to know the information, there exists a data sharing agreement referenced above, or release of the information falls within one of the exemptions of the Privacy Act.

 

OMB Control Number 3045-0006

 

Expiration Date 6/30/2017

 

PART4

Enrollment Certifying Official: Please Complete and Sign

1. Program:

AmeriCorps State & National:

AmeriCorps National Direct

AmeriCorps State

AmeriCorps Segal Education Award Program

AmeriCorps Tribe

AmeriCorps Territory

AmeriCorps VISTA

AmeriCorps National Civilian Community Corps

AmeriCorps Serve America Fellows

Other (Specify):

2. Type of Enrollment (Mark only one.)

Full-time (17 hours per year, or 365 days per year for VISTA)

VISTA Summer Associate (1-12 weeks)

Half-time (9 hours in no more than 2 years)

Half-time (9 hours in no more than 1 year)

Reduced half-time 675 hours

Quarter time 45 hours

Minimum time/Summer 3 hours

3. Will the member receive a living allowance?

Yes

No

4. Education Award Amount: ____________

5. Program Information

Name of Program or AmeriCorps NCCC Campus

Operating Site I.D. Number

Street Address

City

State

Zip Code

Business Phone

Ext

I understand that a knowing and willful false statement on this form can be punished by a fine or imprisonment or both under Section 11of Title 18. U.S.C or other actions authorized by the Civil Fraud Remedies Act, 31 USC 381-3812.

Signature of Certifying Official Date

Name of Certifying Official (Please Print):