S.E.E. AmeriCorps Community Service Program
Member Application
Applicant’s Name:_____________________________
APPLICATION CHECKLIST
_____ Application Form
Please type or use black or blue ink. Make sure your responses are legible.
_____ Personal Essay
Please review the instructions in the application on personal essays.
_____ Class Schedule
Please include a copy of the schedule for the term you are applying for.
*** All items must be included in order for your application to be considered. Once a completed
application is submitted, the applicant may be contacted to an interview. Applications can be submitted either
directly to our office or through the mail. NO FAXED OR EMAILED COPIES WILL BE ACCEPTED! Our
contact information is listed below.
S.E.E. West Monroe AmeriCorps
400 South Fifth St
West Monroe, LA 71292
Phone: 318-387-4001
Or
Email: drothell@westmonroe.la.gov
PERSONAL PROFILE
1. NAME:________________________________________________________________________________
LAST
FIRST
MIDDLE
2. AmeriCorps members must be a United States citizen, U.S. national or lawful permanent resident. Are you a United States
citizen, national, or lawful permanent resident alien?
□ Yes □ No
If you are a lawful permanent resident alien and you received your card after January 1987, what is
your registration number and card expiration date? ____________________________________
3. DATE OF BIRTH: _________________
MONTH/DAY/YEAR
4. GENDER: □ Male □ Female
5. Earliest date you are available to begin service: ____________________
MONTH/DAY/YEAR
6. CURRENT ADDRESS: All information will be sent to this address unless you notify us of a change.
______________________________________________________________________________
NUMBER AND STREET (IF POSSIBLE, INCLUDE A NUMBER AND STREET ADDRESS WHEN USING A P.O. BOX)
_______________________________________________________________________________
CITY
STATE
ZIP CODE
Home Phone (_____)__________________ Work Phone (_____)_______________________
Cell Phone (_____)____________________ E-Mail ________________________________
9. Are you moving within the next six months? □ Yes □ No If yes, when*? _________________
*Please notify us of new address at time of move.
MONTH/DAY/YEAR
10. EMERGENCY CONTACT/PERMANENT ADDRESS (if different than above): Please give the name and address of a person
through whom you can always be reached:
Name: _______________________________________ Relationship: ______________________
FIRST
LAST
_______________________________________________________________________________
NUMBER AND STREET (IF POSSIBLE, INCLUDE A NUMBER AND STREET ADDRESS WHEN USING A P.O. BOX)
________________________________________________________________________________________
CITY
STATE
ZIP CODE
Home Phone (_____)__________________ Work Phone (_____)_______________________
Cell Phone (_____)____________________ E-Mail __________________________________
EDUCATION
11. Check the highest level of education that you will have completed by the time you are planning to serve in
AmeriCorps. (Check only one.)
□ Some high school
□ Associate's degree
□ Graduate degree
□ High school diploma or GED
□ Some college
□ Other(please specify):
□ Technical school/Apprenticeship
□ Bachelor's degree
____________________
12. List all schools after high school that you have attended, including trade or technical schools, military training and
employment training programs.
EMPLOYMENT
12. Beginning with the most current or most recent position, list and briefly describe the last two positions you have held
or your last ten years of employment. Begin with the current or most recent and go back ten years. Include selfemployment, internships/fellowships, home management, and full- or part-time paid or unpaid work experience.
SKILLS AND EXPERIENCE
13. Listed below are skill areas that some programs find useful and may seek in AmeriCorps applicants. Indicate the skill
areas in which you have had training or experience, including volunteer or community service experience, and indicate
how you gained those skills.
EXAMPLE:
 Public Speaking Club President
□ Architectural Planning ____________________
□Business/Entrepreneur ___________________
□ Communications ________________________
□Community Org./Development _____________
□Computers/Technology ___________________
□Conflict Resolution_______________________
□ Counseling_____________________________
□ Education _____________________________
□ Fine Arts/Crafts _________________________
□ First Aid _______________________________
□ Fundraising/Grant Writing _________________
□ Law _____________________________
□ Leadership________________________
□ Medicine _________________________
□ Public Health ______________________
□ Public Speaking____________________
□ Recruitment _______________________
□ Teaching/Tutoring __________________
□ Trade/Construction__________________
□ Writing/Editing _____________________
□ Youth Development _________________
□ Other (specify): ____________________
14. Do you have a valid driver’s license? □ Yes □ No
License # __________________State_____
CRIMINAL HISTORY
The AmeriCorps application process requires a criminal history check to ensure that community members with whom we
work are protected, particularly children, individuals with disabilities, and individuals over 60 years old. We will investigate
for past sexual offenses and violent crimes, or crimes that would have a direct bearing on your service. This background
check will entail our earch of the National Sex Offenders Registry and an FBI criminal history check, which will require
your being fingerprinted at Pre-Service Orientation. You will not be permitted to serve or work with children, individuals
with disabilities, or individuals over 60 years of age, without supervision until the history check is complete and you are
cleared. The review process is not lengthy, and normally is completed within weeks.
Answer the following questions fully. Existence of a criminal conviction or juvenile adjudication may or may not, depending
on the circumstances, disqualify you from consideration. However, any intentional misrepresentation or omission will
disqualify you. Do not include minor traffic violations.
□ I allow the AmeriCorps program to complete an NSOPR check and criminal background check.
16. Have you ever been convicted as an adult, or adjudicated as a juvenile offender, of any criminal
offense by either a civilian or military court, other than minor traffic violations?□ Yes □ No
Are you currently facing charges for any offense or on probation or parole? □ Yes □ No
If no, skip to “Certification” below. If you answered “yes” to any of the questions above, please provide the following
information:
Date: ___________________________ Place: _________________________________________
MONTH/DAY/YEAR
CITY, STATE
Charge: _________________________________________________________________________
Action Taken: ____________________________________________________________________
Court, Probation, or Parole Officer: ___________________________Phone: (_____ ) ___________
Name: __________________________________________________________________________
Address: ________________________________________________________________________
NUMBER AND STREET
______________________________________________________________________________
CITY
STATE
ZIP CODE
You may attach any additional information or explanation on a separate sheet.
CERTIFICATION
If you choose to submit a paper application, your application must be certified with your original signature in ink. If you are
applying to more than one AmeriCorps program, make a copy for each program that you’re applying to first, and then sign
each one. By signing this application, or by submitting it electronically if applying on-line, I certify that all of the statements
made in this application are
true, correct, and complete, to the best of my knowledge, and are made in good faith. Misinformation or omission of
information could result in disqualification or termination as an AmeriCorps member. If I am selected for participation in
some AmeriCorps programs, including AmeriCorps NCCC, I may be required to submit to a physical examination,
including drug or alcohol testing. Background and security checks may also be conducted by some programs.
PRIVACY ACT NOTICE: The Privacy Act of 1974 (5 U.S.C § 552a) requires that the following notice be provided to you:
The authority for collecting information from you in this application is contained in 42 U.S.C 12592 and 12615 of the
National and Community Service Act of 1990 as amended, and 42 U.S.C 4953 of the Domestic Volunteer Service Act of
1973 as amended. You are advised that submission of the information is entirely voluntary, but the requested information
is required in order for you to participate in AmeriCorps programs. The principal purpose for requesting this personal
information is to process your application for acceptance into an AmeriCorps program, and for other general routine
purposes associated with your participation in an AmeriCorps program. These routine purposes may include disclosure of
the information to federal, state, or local agencies pursuant to lawfully authorized requests, to present and former
employers, references provided by you in your application, and educational institutions, for the purpose of verifying the
information provided by you in your application. In some programs, the information may also be provided to federal, state,
and local law enforcement agencies to determine the existence of any prior criminal convictions. The information will not
otherwise be disclosed to entities outside of AmeriCorps and the Corporation for National and Community Service without
your prior written permission.
____________________________________________________________________________________
SIGNATURE
DATE
Print Name: _____________________________________________________________________
For Parent or Guardian of Applicants Under 18 Years of Age: I have reviewed this application and I authorize my
son/daughter/legal ward to apply to AmeriCorps.
____________________________________________________________________________________
SIGNATURE
DATE
Print Name: ___________________________________________________________________
RELATION: _____________________________________ PHONE: (______)_________________
ADDRESS_______________________________________________________________________
CITY
STATE
ZIP CODE
(IF P.O. BOX, ALSO GIVE NUMBER AND STREET)
OPTIONAL INFORMATION
HOW DID YOU HEAR ABOUT AMERICORPS? You may check more than one.
□AmeriCorps representative
(Service/career fair, conference, information session)
□ Armed Forces
□ Current or former AmeriCorps member
□ Friend/Relative
□ Internet/Listserv/E-mail
□ Newspaper/Magazine advertisement
□ Other service organization
□ Radio story
□ Television advertisement
□ Poster at school
□ College guidance office/Placement office
□ Department of Education
□ High school guidance counselor
□ Newspaper/Magazine article
□ Peace Corps
□ Radio advertisement
□ Received information in the mail
□ Television news story
□ Other (specify) ______________________
WHAT IS YOUR ETHNICITY? (optional) □Hispanic or Latino □Not Hispanic or Latino
WHAT IS YOUR RACE? (optional) Mark one or more:
□ 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.
PERSONAL ESSAY QUESTIONS
First time AmeriCorps applicants, on a separate page, please write a personal essay about
yourself. Include in your essay answers to the questions listed below. Honest and thoughtful
responses are appreciated. This essay will be used not only to learn more about you but also to
determine your writing skills. Our program is education based and we need applicants that can
contribute academically to our programs.
Why do you want to join AmeriCorps?
What do you hope to gain by joining AmeriCorps?
What could you offer AmeriCorps?
How have you reached out to help others in your community?
What did you learn from the experiences?
What type of service projects or community events have you participated in the include the service
areas of social services/community support, education, and the environment?
Your involvement could include serving in neighborhood, school, youth, religious, or volunteer groups,
helping out with community service projects, or participating in less formal activities such as assisting
an elderly neighbor.
For previous AmeriCorps members, on a separate page, please write a personal essay about
yourself. Include in your essay answers to the questions listed below. Honest and thoughtful
responses are appreciated. This essay will be used not only to learn more about you but also to
determine your writing skills. Our program is education based and we need applicants that can
contribute academically to our programs.
What AmeriCorps program did you serve with?
Why did you join that AmeriCorps team?
Please give a brief description of your service (example: I served in a after school program with Pre-K
students, I was part of beautification efforts in the City of West Monroe, I served as a green corps
member, etc.).
What did you learn most from your first service term?
What has prompted you to apply for a second term of service?
What experiences do you hope to gain from a second term of service?
Please include a color copy of a Driver’s License or Photo ID!
Background Check Procedures for AmeriCorps
(New Applicants & Members returning from a break)
We thank you for applying to the S.E.E. West Monroe AmeriCorps program. As part of our application
process we must perform a State and FBI background check on each individual we select as part of
our program. To ensure that this is a smooth process we ask that you please comply with the
following:
-
Complete the 2 attached forms
Visit the West Monroe Police jail and obtain 2 sets of finger prints
o Remember to keep the cards neat and free of any smudges
o Remember to fill out the information at the top of each fingerprint card
o Return the 2 forms as well as the 2 finger print cards by the day of your interview
 If you do not have your fingerprints by this time you will not be considered for the
S.E.E. West Monroe AmeriCorps team (exceptions to this deadline are extremely
rare and must be approved by the AmeriCorps Coordinator)
- Your fingerprints will only be submitted for background checks if you are selected to the team.
If you are not selected your prints along with the forms you completed will be returned to you.
If you have any questions regarding this process please feel free to contact me at
drothell@westmonroe.la.gov and I will be more than happy to assist you.
Additionally you will find attached information regarding the times that West Monroe Police has
available for fingerprinting. Please bring that sheet with the times on it with you to the jail to verify you
are having them done for AmeriCorps.
Thank you for your help with this process!
Dylan Rothell
Volunteer Coordinator
West Monroe Community Center
400 South 5th St
West Monroe, La
318.397.6839 Work
318.953.4362 Cell
drothell@westmonroe.la.gov
Procedure for Fingerprinting
1.
2.
3.
Go to: West Monroe City Jail (396-0440).
-Monday & Thursday 8:00-10:30 am
-Tuesday & Friday 8:00-10:30 or 1:00-3:00
-You will need a STATE ISSUED photo ID
Tell them you need fingerprints for SEE West Monroe AmeriCorps
Bring TWO SETS of prints to Dylan Rothell
-Do not smudge prints or you will have to pay to redo them
If they have any questions the can call Dylan at 953-4362
SEE West Monroe AmeriCorps
National Service Criminal History Check Consent Form
I, ____________________, agree to undergo the National Service Criminal History
Check, which may include one or both of the following: Checks of state criminal
history registries for locations where I’ve lived as well as where I will serve or work
and/or an FBI fingerprint check.
I also understand that selection in SEE West Monroe AmeriCorps is subject to
check results and that a candidate can be disqualified for any one of the following
reasons:
1. Murder conviction
2. Required to be registered on a sex offender registry
3. False statement in response to inquiry about criminal history
4. Refusal to undergo the National Service Criminal History Check
Name (printed): ___________________________________________
Signature:_________________________________________________
Date:_____________________________________________________