Form PC-2192 Peace Corps Response Reinstatement Application 2020

Peace Corps Response Expedited Application

PEACE CORPS RESPONSE 2020 RETURN TO SERVICE
Questions marked with an asterisk (*) are required.
Instructional text is in italics.

Start Your Submission
Estimated completion time: 10-15 minutes
Thank you for your interest in returning to serve with Peace Corps Response. Please review the following
information before proceeding with your request.
You will only need to submit one application. Our Recruitment & Placement team will work with you to potentially
return you to your original assignment or identify another assignment departing as soon as possible. We cannot
guarantee you will be able to return to your original assignment, nor can we guarantee we will have a substantially
similar opening in the near future.
OMB Control Number: [original number: 0420-0547]
Expiration Date: 10/31/2020
Privacy Act Notice

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.).
*First name (your legal/given name)
Middle name (no initials)
*Last name
*Mobile phone
Other phone
*Permanent email address
CURRENT MAILING ADDRESS
Please ensure you can collect mail in a timely manner from this address as important, time-sensitive forms will be
sent here.
*Country
*Current Address Line 1
Address Line 2
*City
*State/Region/Province
*ZIP/Postal code

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Peace Corps Response Expedited Application

Peace Corps Service History
* While serving as a Peace Corps Response Volunteer, were you granted Medical Separation, Interrupted Service,
or early Close of Service (i.e., due to the evacuation) within the past year?
Yes
No
If no:
Thank you for your interest in serving with Peace Corps Response. The information you entered indicates you do not
meet eligibility requirements at this time. The return to service expedited application is exclusively for Returned
Peace Corps Response Volunteers who left service early in the past year.
If you are a U.S. citizen and at least 18 years of age, please consider the two-year Peace Corps program or Peace
Corps Response openings currently on our website.
*What is your most recent Peace Corps Response country of service?
Comprehensive list of all countries where Peace Corps has sent Volunteers.
*When did you serve there? (text box)
*Did you use a language other than English during your most recent service?
Yes
No
If yes:
*Please select the language.
Comprehensive list of languages.
*Please select the level of proficiency.
Basic
Intermediate
Advanced
Superior

Returning to Service
*Please indicate your preference for returning to service as a Peace Corps Response Volunteer.
I only want to return to serve in my original assignment.
I only want to be considered for new assignments.
If my original assignment is unavailable, consider me for new assignments.
*Are you available to serve for 12 months?
Yes
No

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Peace Corps Response Expedited Application

If no:
How many months could you serve?
List from 3 to 11
*Please provide your earliest availability date:
Motivation Statement
*In one paragraph, please describe why you want to return to Peace Corps Response service. (2,000 character
limit)
Couples
If you were previously serving as a couple in Peace Corps Response, please provide your spouse or domestic
partner’s information here. If you were most recently serving independently, you may not return to service with a
spouse or domestic partner.
*Do you plan to return to service with your spouse/domestic partner?
Yes
No
Not Applicable
If yes:

*Spouse/domestic partner’s name: (text box)

Resume Upload
Please upload or select your previously uploaded resume below. If you are interested in returning in a different
assignment, please update your resume with your most recent Volunteer experience.
By uploading your resume, you agree to permit the Peace Corps to share the information in it with host country
agencies and counterparts, other Volunteers, and others the Peace Corps deems necessary or appropriate in
connection with your application or possible future Peace Corps service.
Resume/CV
Add a resume/CV to include with your submission.

Legal Status Update
Please provide an update on your legal status since your previous legal clearance. If you reply “yes” to any of the
following questions, provide any pertinent detail. You will be contacted with a request for further information.
*Since receipt of your last Peace Corps legal clearance or Completion of Service (COS) date, have you been
arrested, charged, cited or convicted of any offense? Exclude minor traffic violations, traffic citations, and parking
tickets less than $300.
Yes (Text area)
No

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Peace Corps Response Expedited Application

*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?
Yes (Text area)
No
*Have you or a family member been employed by or connected with an intelligence agency, or engaged in
intelligence activity or related work?
Yes (Text area)
No
*CERTIFICATION: By submitting this form, I certify that all of the statements made in this update are true, correct,
and complete to the best of my knowledge and are made in good faith. I understand that if I fail to disclose any
required information about my legal history – including expunged or sealed cases – or drug/alcohol behavior, the
Peace Corps may revoke my invitation to serve or disqualify my from Peace Corps service.
Agree

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 of Peace Corps service. Any
intended omission or intentionally false statement may constitute a violation of federal and state laws and subject
you to severe civil and criminal penalties, including fines and/or imprisonment pursuant to 18 U.S.C. 1001.
I also understand it is my responsibility throughout the process, up through the start of service, to inform the
Peace Corps promptly of any changes to the information provided here. Failure to do so may be cause for
disqualification or termination of Peace Corps service.
*Signature Line (Name)
*Today’s Date (m/d/yyyy)
Review
This page includes all the applicant’s answers from their request. There are no instructions but each section has an
edit function which allows them to return to that section and edit any information as necessary. The “Send my
application” button is listed at the bottom of this page.
Application Submitted
Thank you for your interest in returning to service as a Peace Corps Response Volunteer. If you have expressed an
interest in returning to a new assignment, please do not submit a separate application to our current openings.
We look forward to working with you.
(COVID-19 Evacuee FAQs)

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Peace Corps Response Expedited Application

NOTE: Privacy Act included as link on the first page of the application.
Privacy Act Statement
The Peace Corps, a U.S. government agency, 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 form is authorized by the Peace Corps Act (22 U.S.C. 2501 et seq.) as amended.
B. The information you provide will be used 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 PC-17 and PC-21.
D. The completion of this application is voluntary. However, failure to complete the application will result in the
Peace Corps’ inability 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 and accounting purposes.
Paperwork Reduction Act Burden Statement
Public reporting burden for this information collection is estimated to average one hour. The burden for the
expedited application information collection is 15 minutes. This includes the time for reviewing instructions and
completing the information. This is a 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, 1275 First Street NE, Washington,
DC 20526.
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], 1275 First Street, NE,
Washington, DC 20526.

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