Apply for AmeriCorps

Belleville AmeriCorps Application Form

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
MM slash DD slash YYYY
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.
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School/Institution	City/State	Dates Attended	Area of Study	Degree/Certificate	Date Received

Employer	Position	Dates	Reason for Leaving	Supervisor	Phone Number

Activity Description	Organization	Dates

Type of Conviction	Date	Disposition

Belleville AmeriCorps Application Form

Position

Application Information

Education

Employment Record

Volunteer Experience

Availability

Personal Statement

Felony Convictions

Optional Demographic Information

Certification of Application