For Departing Trainees

Hometown News Release

your contact information

This release is used to inform the press that you will be going
into the Peace Corps. Completing it is optional, but we encourage you to answer each question thoroughly so that we can share
accurate information with the media. Please fill out both sides,
print clearly, and be sure to sign and date the form. Attach additional sheets if necessary. Thank you.

name
e-mail address
phone number

publications

Please list your hometown (or nearest city) newspapers, or other

publications in any format that you would like included in any distribution of this release. Dont forget about your college or university newspapers! Please include contact information for the publications if it is available. In addition to the publications you listed,
the Peace Corps will release and publish the information contained in this form to any publication it deems appropriate.

name
contact
name
contact
name

When you have filled out both sides of this form,

please mail or fax it to:

contact

Peace Corps
Press Office
1111 20th Street NW 8th Floor
Washington, DC 20526
Fax: 202.692.1379

name
contact

model press release

Check this box if you wish to restrict release and publication of

your information to only the publications you listed on this form.

Please fill in the blanks and circle the relevant choice where indicated.

_____________________________________________________________________________________________________________RESIDENT JOINS THE PEACE CORPS

Hometown (City, State) | Current City and State of Residence (Please circle one)

__________________________________________________________________________ ,___________ , the son | daughter | parent of___________________________________________________________________________ ,

Trainees Name: First, Middle, Last

Age

(Circle one)

Relatives First and Last Name(s), Residence (City, State)

has been accepted into the Peace Corps. He | She will be departing for_ ____________________________________________________________ on___________________________________ to

Circle one

Country of Service

Estimated Departure Date

become a(n)_______________________________________________ Volunteer. ______________________________________________s work will include___________________________________________________

Assignment Name

Trainees Last Name

___________________________________________________________________________________________________________________________________________________________________________________________________________
Brief Description of Program and/or Duties, if Known

A graduate of____________________________________________________________________________________ in________________________________________________________________________ , he | she attended

Full Name of Trainees Secondary (High) School

Location of Secondary School in City, State

(Circle one)

_____________________________________________________________________________________________ in________________________________________________________________________________________ and earned a

Full Name of Trainees College or University

Location of Trainees College or University

_________________________________________________________________ in__________________________________________________________________________________________ , graduating in_________________ .

Degree Title

Major(s)

Year

_____________________________________ previously worked_____________________________________________________________________________________________________________________________________________

Trainees Last Name

Trainee: List Previous Experience You Consider Most Relevant and the City, State in which you worked

___________________________________________________________________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________________________________________________________________

On this page, please add a few remarks (complete sentences please) regarding the following:
1. Personal information of interest (marital status, children, hobbies, travel experience, college organizations, activities, etc.)

2. What motivated or attracted you to join the Peace Corps?

3. What have been some factors that affected your decision to become a Volunteer?

4. Did family, friends, or returned Peace Corps Volunteers influence your decision to join the Peace Corps? If so, how?

5. List the place(s) of residence of family members, if you would like this information released to the press in their home town(s):

6. What are your career goals once you complete your Peace Corps service?

7. Include any other information you think is relevant.

Privacy Act Notice: This notice is provided under the Privacy Act of 1974, as amended (5 u.s.c. 552a). The information requested is collected under the
authority of the Peace Corps Act, 22 u.s.c. 2501 et seq., for the purposes of preparing news reports and other public information for the Peace Corps.
This information may also be used for the routine uses described in the Privacy Act, 5 u.s.c. 552a, and in the Federal Register at 65 Fed. Reg. 53,722
(September 5, 2000) and 50 Fed. Reg. 1950, 1962 (January 14, 1985) regarding Peace Corps systems of records pc-17 (Volunteer Records). Providing the
material herein is completely voluntary, but failure to authorize the release of this information will make it impossible to provide press releases and other
public information regarding your background before you became a Volunteer and your activities while in service. Your signature hereby authorizes the
release and publication of any and all information contained herein unless revoked in writing.

Signature___________________________________________________________________________________________________________________________ Date________________________________________________
pc-909.5-1a (rev. 09/2007)