Apply for AmeriCorps | Southwestern Illinois College

Position

I would like to be considered for the following position:

Application Information

Name (Legal)*

First Last

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Are you a U.S. citizen, national or lawful permanent resident alien?*

Yes
No

Will you be 17 years old or older as of the start date of service?*

Yes
No

Education

Please select the highest grade you have completed:

High School*

9
10
11
12

GED*

Yes
No

College*

1
2
3
4

Graduate School

1
2
3
4

Beginning with ninth grade, list the educational institutions you have attended.*

School/Institution	City/State	Dates Attended	Area of Study	Degree/Certificate	Date Received

Employment Record

Please describe your employment record. List the last five positions you have held. Be sure to include any experience you have which may be relevant to your service as a Belleville AmeriCorps member. You may send us a résumé if you wish.*

Employer	Position	Dates	Reason for Leaving	Supervisor	Phone Number

Please click and type this information in the boxes below.

Are you currently on lay-off status, subject to recall?

Yes
No

Volunteer Experience

List and describe any volunteer experience and/or community involvement.

Activity Description	Organization	Dates

Availability

Please list the days and hours you are available to serve with Belleville AmeriCorps.*

Personal Statement

Why do you want to participate in Belleville AmeriCorps?*

What will you do, as a participant, to ensure the success of the Belleville AmeriCorps program?

Briefly explain how your professional, volunteer and educational experiences would be helpful to you as a Belleville AmeriCorps member.

Felony Convictions

Have you ever been convicted of a felony?*

Yes
No

List*

Type of Conviction	Date	Disposition

Optional Demographic Information

Ethnic Background

African American
White/Non-Hispanic
Hispanic/Latino
Asian American/Pacific Islander
American Indian/Alaskan Native
Other

Accomodations

Do you have any special needs that require accomodation?

Yes
No

If so, specify:

Public Assistance

Does your family receive public assistance (e.g. TANF, Food Stamps, Medical Card)?

Yes
No

If yes, please specify:

Household Information

Total annual household income from all sources	How many people reside in your household?

Date of Birth

Certification of Application

The statements that I have made in this application are true and complete to the best of my knowledge and I understand that any alteration or concealment of a material fact will result in my disqualification before appointment or dismissal after appointment. I understand that Southwestern Illinois College is a drug-free workplace and that I must be drug-free at the time of appointment and throughout my term of service. I will be required to submit to a criminal background check. I hereby authorize Southwestern Illinois College or its representative to investigate my background, including but not limited to past employment, military and police records. My permission is hereby given to any and all persons, agencies, corporations, firms or associations to release any and all such information, records or other documents to Southwestern Illinois College or its representative for its inspection and copying. A copy hereof shall be considered equally authentic as the original.