Western Illinois University-Quad Cities/WQPT Early Childhood Literacy
AmeriCorps Program Application
I. Personal Profile
1. Name:
Last:________________ First:________________ Middle:________________
2. Previous Name(s):
(Alias):_________________________________________________________
3. Street Address (No P.O. Boxes):___________________________________
City:________________ State:________________ Zip Code:______________
4. Cell Phone:_________________________
Work Phone:________________________
5. Email: ___________________________
6. Position Applying for: Early Childhood Literacy Guide
7. Have you served in an AmeriCorps Program before? Yes
No a. If yes, which one(s)? (circle if applicable) Learn & Serve / State / National / VISTA / NCCC b. If yes, please indicate where you served, hours served, and if you
earned an education award:_____________________________________
___________________________________________________________
c. If yes, have you completed and been exited from the program? Yes No
8. Are you a United States citizen, national, or lawful permanent resident?
Yes
No
9. Have you been a convicted of a crime, plead guilty or been released from
prison within the past seven (7) years? Yes
No
10. If yes, indicate the date and nature of the offense: ___________________
______________________________________________________________
11. Date available to start work:_____________________________________
II. Education and Training
Check the highest level of education you will have completed by the time you
plan to serve in our program:
__ High School Diploma or GED
__ Associates Degree
__ Bachelor’s Degree
__ Graduate Degree
__ Other (please specify) Please indicate expected graduation date if you have not yet graduated:_______
Highest Education Level:
School Name:_____________________________________________________
City, State:_______________________________________________________
Course of Study:___________________________________________________
Dates Attended:___________________________________________________
Related Certificates or Licenses:______________________________________
Seminars or Other Training:__________________________________________
III. Experience
This section must be completed in detail. Begin with your present or most recent experience. Include periods of employment, self-employment, military service,
part-time jobs and any job-related volunteer experience.
Employer Name:___________________________________________________
Address:_________________________________________________________
Telephone Number:________________________________________________
Position Held:_____________________________________________________
Employment Dates- From:__________________ To:______________________
Name and Title of Supervisor:________________________________________
May we contact this employer? Yes No
Duties and Responsibilities:__________________________________________
Reason for leaving:_________________________________________________
Employer Name:___________________________________________________
Address:_________________________________________________________
Telephone Number:________________________________________________
Position Held:_____________________________________________________
Employment Dates- From:___________________ To:_____________________
Name and Title of Supervisor:_________________________________________
May we contact this employer? Yes No
Duties and Responsibilities:__________________________________________
Reason for leaving:_________________________________________________
Employer Name:___________________________________________________
Address:_________________________________________________________
Telephone Number:________________________________________________
Position Held:_____________________________________________________
Employment Dates- From:____________________ To:____________________
Name and Title of Supervisor:_________________________________________
May we contact this employer? Yes No
Duties and Responsibilities:__________________________________________
Reason for leaving:_________________________________________________
IV. Personal Statement
Please answer the following questions.
1. Why do you want to join the AmeriCorps Program?
2. How would you describe your commitment to community involvement?
3. What has prepared you to work with low-income, underserved early
childhood students?
V. Professional References
Please complete the information below for each of your references.
Name:___________________________________________________________
Phone Number:____________________________________________________
Email Address:____________________________________________________
Street Address:____________________________________________________
City, State, Zip Code:_______________________________________________
Occupation:_______________________________________________________
Years Known:_____________________________________________________
Relationship:______________________________________________________
Name:___________________________________________________________
Phone Number:____________________________________________________
Email Address:____________________________________________________
Street Address:____________________________________________________
City, State, Zip Code:_______________________________________________
Occupation:_______________________________________________________
Years Known:_____________________________________________________
Relationship:______________________________________________________
Name:___________________________________________________________
Phone Number:____________________________________________________
Email Address:____________________________________________________
Street Address:____________________________________________________
City, State, Zip Code:_______________________________________________
Occupation:_______________________________________________________
Years Known:_____________________________________________________
Relationship:______________________________________________________
VI. Applicant’s Certification and Agreement
Please read the following carefully before signing this application.
I hereby certify that all information in this application form is true and correct to
the best of my knowledge and agree to have any of the statements checked by
Western Illinois University-Quad Cities. I understand that any misrepresentation,
falsification, or material omission of information on this application may result in
my failure to receive an offer or, if I am hired, my termination from Western
Illinois University-Quad Cities AmeriCorps Program. I authorize the references
listed above to provide Western Illinois University-Quad Cities any and all
information concerning my previous employment and any other pertinent
information that they may have. Further, I release all parties and persons from
any and all liabilities for any damages that may result from furnishing such
information to Western Illinois University-Quad Cities as well as from the use or
disclosure of such information by Western Illinois University-Quad Cities or any
of its agents, employees, or representative. I understand that all offer of Western
Illinois University-Quad Cities AmeriCorps opportunities are conditioned on the
provision of satisfactory proof of applicant’s identity and legal authority to work in
the U.S. I understand that AmeriCorps member opportunity with Western Illinois
University-Quad Cities may rely upon information received relating to reference
requests.
I understand that the information contained in this member application or my
being invited to participate in any stage of the hiring process is NOT intended to
create an employment contract between Western Illinois University-Quad Cities
and myself.
By signing below and submitting my application, I acknowledge that I have read,
understand, and agree with the above statements.
Signature of Applicant:______________________________________________
Date:______________