Peace Corps Online Application 2008 Copy 2

Peace Corps Online Application
Instructions
Thank you for your interest in becoming a Peace Corps Volunteer. These instructions
were developed to helpguide.you through the process of completing your Peace
Corps online application. We recommend that you print this document and refer to it
as you move through the application.
Application Overview
The Peace Corps application has two parts: the Volunteer application and the Health
Status Review. Both of these are available through this website,
https:/Iapp.applyyourself.coml?id=pc. Once you have completed the Volunteer
application, you will be prompted to begin the Health Status Review. Please note that
you must complete both the Volunteer application and the Health Status Review in
order for your application to be submitted to 'our recruiters.
Volunteer Application
The Volunteer Application asks questions about your education, work experience,
volunteer experience, and your financial and legal situation. It also requires you to
complete two essay questions, one addressing your motivations for serving in the
Peace Corps and one addressing your cross cultural experience.
It is extremely important to answer all questions fully and completely, and to provide
complete and accurate information to us throughout the application process, so that
the Peace Corps is able to make appropriate decisions about selecting and placing
Peace Corps Volunteers. We may disqualify an applicant (or administratively
separate a Trainee or Volunteer) if we determine that an applicant has provided
misleading, inaccurate or incomplete information during the application process. An
intentionally false statement may be subject to fines and imprisonment pursuant to
18 U.S.C. §1001.
While it is possible to complete the entire Volunteer application in one sitting, you
may find it easier to work in sections. Just be sure to save your changes before you
exit the online application. You may return to the URL listed above to continue your
"
application at any time.
Before you get started, you will need to assemble the items and information on the
following list.
Information You Will Need
• Addresses and dates for former employment and volunteer work during the
last ten years.
• A current resume.
• Your Social Security Number.
• Names, addresses, telephone number and email addresses of three
references.
PC-1502 (Revised 6/05) (All previous editions are obsolete)

OMB #0420-0005
• Information about your student loans and other financial obligations.

• Answers to two essay questions (written in Microsoft Word and uploaded).
Supplemental Materials To Mail Separately
After you submit your online application, you must submit the following items by
mail in order for your application to be considered complete:
• College transcripts for any school attended since high school. High school
transcripts are not required. An unofficial transcript is acceptable if it includes
applicant identifying information (i. e. full name or social security number)
and the name of the college or university. The transcript must be current,
showing graduation related information (degree, major, date awarded) for
applicants who have completed their studies.
• Copies of any applicable professional licenses.
• If applicable: marriage certificates and divorce decrees
Please mail supplemental items directly to your regional recruitment office. Mailing
addresses for all Peace Corps recruitment offices can be found on our website at
http://www.peacecorps.gov/contactus.
References
References are required. Please choose reference providers who best know your
qualifications for Peace Corps service and who wili respond promptly.
Please note that the Peace Corps requires three different types of
references: 1) A current or former job supervisor; 2) current or former volunteer
work supervisor; 3) a personal acquaintance. You may not use family members or
persons with whom you are romantically involved. If you have any questions
regarding appropriate references, please contact your Peace Corps Regional Office.
Peace Corps Application Part II: Health Status Review
Once you have completed the Volunteer Application, you will be prompted to
complete the Health Status Review (HSR). You must complete the HSR in order to
submit your application.
Completing the HSR is the first step in your Peace Corps medical screening. This
portion of the application asks for information about your medical and dental history.
Please answer all questions truthfully. To serve as a Peace Corps Volunteer, you
must be medically and dentally screened and qualified. If you are nominated for
Peace Corps service, you will receive additional forms and instructions for completing
your medical and dental examinations.
Submitting Your Application
Once you have completed both the Volunteer Application and the Health Status
Review and are ready to submit your application, click on "Check Your Application" to
ensure you have entered all of the required information. Please be sure to double
check the names and addresses of your references. Also, to expedite the processing
of your application, please confirm that you have entered your Social Security
Number accurately.
PC - 1502 (Revised 6/02) 2 (All Previous editions are obsolete)
OM B #0420-0005
If You Are Applying As a Couple
You must be legally married to apply to the Peace Corps as a couple. Each of you
must fill out your own application and obtain your own references. For newlyweds,
the Peace Corps must have a marriage certificate and any name change
confirmations at least six months prior to your listed availability date (Item 2 of the
Vol unteer Appl ication).
If You Have Questions
If you have technical questions about filling out the Volunteer Application, please
click on the "Tech Support" link at the top of each screen. Questions about the Peace
Corps can be answered on the website or by contacting your Regional Recruitment
Office at 1-800-424-8580.
We look forward to receiving your application.
IMPORTANT
The Peace Corps does not discriminate based on race, color, national origin,
religion, sex, handicap, political affiliation, or sexual orientation. Anyone who
feels he or she has been discriminated against should contact the Peace Corps
American Diversity Office, Washington, DC 20526.

OMB #0420-0005
Peace Corps Volunteer Application
Type or print legibly in black ink

1. Full Legal Name
First Middle (not initial) Last

2. Please enter the earliest date you will be available for Peace Corps service. You
will be considered for assignments beginning after this date. You must notify your
Recruiter if this date changes.
_ _---II 1 _
Month Day Year
3. Have you previously: If yes, please provide dates and location

a. Submitted a Peace Corps application? _ Yes _ No _
b. Participated in Peace Corps training? _ Yes _ No _
c. Served as a Peace Corps Volunteer? _ Yes _ No, _
4. Are you applying to the Master's International Program? Yes No

Schoo1 _
5. Peace Corps Volunteers must be U.S. Citizens or Nationals.

a. Are you a U.S. citizen? Yes No
If yes, give place of birth.
City, State, Country
b. If you are/will be a naturalized citizen, prOVide certificate of naturalization

number or expected date of naturalization: _
Note: You cannot be offered a Peace Corps invitation until you are sworn in as a
naturalized citizen.

OMB #0420-0005
6. Address
A. Current Mailing Address
All information will be sent to this address until the Peace Corps receives
notice of a change of address.
Number and Street Apt. No.
City/State/Zip
Home Phone
Work Phone
Permanent e-mail address (Temporary university or college email addresses
are not recommended)
B. Name and address of person through whom you can always be reached:
First name Last name Relationship
Number and Street Apt. No.
City/State/Zip
Home Phone
Work Phone
Email address
C. Do you expect to move in the next 12 months? Yes No
If yes, when? , , _
Month Day Year
Please notify your Recruiter of any change in either your address or that of the
person through whom you can be reached.
7. Social Security Number
Privacy Act Statement
This·information requested is being collected under the authority of the Peace Corps Act, 22
U.S.C. 2519, to complete a background check on all Volunteers. This information may be
used to ensure that our records are accurate, and for tax and other financial accounting
purposes. Failure to provide this information will result in your ineligibility for Peace Corps
Service.
PC - 1502 (Revised 6/02) 5 (All Previous editions are obsolete)·

OMB #0420-0005
8. Date of Birth
_ _--J1 1 _
Month Day Year
9. Gender Female Male
10. Racial and Ethnic Data
Please select one or more of the c1assific;:ations in each of the two sections
below:
Ethnicity:
Hispanic (a person of Mexican, Puerto Rican, Cuban, Central or South

American, or other Spanish culture or origin, regardless of race)
Not Hispanic or Latino
Race:
American Indian or Alaskan 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. This area includes, for
example, China, India, Japan, Korea, Malaysia, Pakistan, the Philippines,
Thailand and Vietnam.
Black or African American - A person having origins in any of the black
racial groups of Africa. Terms such as "Haitian" or "Negro" can be used in
addition to "Black or African American" not of Hispanic origin
Native Hawaiian or Other Pacific Islander - A person having origins in any
of the original peoples of Hawaii, Guam, Samoa and other Pacific islands
White, haVing origins in any of the original peoples of Europe, the Middle
East or North Africa.
The Peace Corps is asking for data about race and ethnicity for internal
program administration and statistical purposes. Your response will not
affect consideration of your application.
11. Legal Information
Note: If you fail to disclose any required information regarding legal, financial
or drug and alcohol behavior, the Peace Corps may revoke your invitation to
serve, or disqualify you from Peace Corps service. Any misleading, inaccurate,
or incomplete information may be cause for disqualification or termination. In

OMa Control 110420-0005
addition, any intentionally false statement may be subject to fines and/or

imprisonment pursuant to 18 U.S.C. Section 1001.
A. Drug and Alcohol Information
The Peace Corps has a strict policy regarding use of drugs and alcohol:
Drugs
A Volunteer or Trainee (V/T) found to be involved with drugs in a manner not

authorized for medical purposes, in any way in any country, will be administratively
separated immediately. The Peace Corps enforces this strict policy because the
cultivation, manufacture, traffic, and use of drugs, including marijuana, are illegal in
most countries. Additionally, drug involvement by Volunteers and Trainees in any
country could seriously jeopardize the entire Peace Corps program, as well as the
safety and health of Volunteers and Trainees.
Applicants with any drug-related arrest or conviction in their legal history will not
have their application considered for Peace Corps service until one year has passed
from the date of the arrest or conviction, whichever is later.
Alcohol
Peace Corps leaves decisions regarding the use of alcohol to the discretion of the
individual VIT. Peace Corps recognizes, however, that excessive use of alcohol
may compromise VIT safety and security, lead to behavior which is a discredit to the
Peace Corps or the individual VIT, or affect the VlT's performance in an
assignment. Examples of such behavior include but are not limited to: public
intoxication, drinking while at the work site, failure to appear for work or training due
to intoxication or hangovers, and verbal or physical aggressiveness while under the
influence of alcohol. Such inappropriate or unsafe behavior or inability to perform
adequately in the assignment may be grounds for disciplinary action, including
administrative separation.
Applicants charged with or convicted of Public Intoxication, DUI, OWl, or who

receive a reduced charge of, or conviction for, Reckless Driving from an initial
charge of DUI or OWl, orwho have a similar alcohol-related offense in their legal
history, are not eligible to have their application considered for Peace Corps service
until one year has passed from the date of the offense or conviction, whichever is
later. This includes arrests and citations.
Please note that any arrests, citations, or other legal incidents related to alcohol or
illegal drugs that occur during the application process, including LiP to the day of
departure, will also disqualify an applicant. An applicant who is disqualified for the
above reasons may reapply after one year.
PC-1502 (Revised 6/05) 7 (All previous editions are obsolete)

OM B #0420-0005
The terms "problem drinking," "abusive use of alcohol," and their variants include,
but are not limited to, binge drinking, consuming more than three ounces of alcohol
in three hours, three times a week for a period of three months, feeling that you
should cut down on your drinking, experiencing others who express concern that you
drink too much, feeling bad or gUilty about your drinking, drinking in the morning to
steady your nerves or get rid of a hangover, or having legal experiences that are
related to alcohol.
Please answer the following questions:
1. Have you ever been arrested for, charged with, or convicted of any offense(s)
related to alcohol or drugs? Yes/No
2. Have you ever been found guilty of an offense under section 404 of the Controlled
Substance Act (21 U.S.c. 844), while under the age of 21? Yes/No
NOTE: Peace Corps reserves the right to ask additional questions about drug and
alcohol use.
B. Other Legal Status
Legal Status and History
Report information regardless of whether the record in your case has been "sealed,"
"expunged," or otherwise stricken from the court record. All Peace Corps invitees
must undergo a National Agency Check (NAC) investigation to help determine
eligibility for service, and the NAC investigation will reveal arrests regardless of
disposition (e.g. suspended sentence, deferred judgment, dismissal, not guilty,
reduced charge, mistaken identity, or expungement). Therefore, it is required that
you disclose to the Peace Corps your official legal history and other experiences. The
NAC form and fingerprint charts will be prOVided at a later date.
Note: It is the responsibility of the applicant to inform the Peace Corps

throughout the application process of any changes in his/her legal status.
1. Have you ever been charged with or convicted of any felony offense? Yes/No
2. Are there currently any charges or probation pending against you for any criminal
offense? Yes/No
3. Have you ever been subject to a court martial or other disciplinary proceedings
under the Uniform Code of Military Justice? (Include non-judicial, Captain's mast,
etc.) Yes/No
4. Have you ever been arrested for, charged with, or convicted of any offense(s) not
listed in questions 1 and 2 in the previous section and/or questions 1-4 above?
(Exclude traffic fines less than $200 unless the violation was alcohol and/or drug
related.) Yes/No
5. Are you currently a party in a civil suit? Yes/No
If you answered "yes" to any questions in section A or section B above, you must
attach information separately with: (1) your name, (2) type of offense/suit (e.g.,
DUI, possession of marijuana, petty theft, suing landlord), (3) complete explanation
and detailed circumstances of each arrest, charge, suit, judgment, or disciplinary
OMB #0420-0005
action, (4) relevant dates, (5) location (city, state, country) of the occurrence, (6)
current status or disposition, and (7) any sentence, probation, community service,
fine or other penalty imposed. Your application will not be considered without the
above information.
12. Financial Obligations:
Before you may serve in the Peace Corps, you must provide documentation
establishing that you have made arrangements satisfactory to your creditor(s) to
defer, pay, or otherwise fulfill all of your financial obligations. The Peace Corps may
run a credit report to verify your financial information.
1. As of the date of this application, do you have any outstanding student loans?
Yes/No
If yes, please provide the following information (attach a separate sheet if
necessary):
Principal Interest
Type of Student Loan Amount Deferrable Yes/No Deferrable
Yes/No
Yes/No
Yes/No
2. As of the date of this application, do you have other financial obligations aside
from student loans (including, but not limited to, a mortgage, credit card debt,
taxes, car loan, alimony, child support)? Yes/No
If yes, please provide the following information (attach a separate sheet if
necessary):
Type of Financial Obligation -----'Amount _

Type of Financial Obligation Amount _
Type of Financial Obligation Amount _
3. Will your student loan(s) and/or financial obligation(s) be paid in fUll, deferred, or
otherwise fulfilled prior to your departure for Peace Corps training? Yes/No
If no, please describe your plans to satisfy the obligation while serving in the Peace
Corps.
Note: If someone is assuming payment of your financial obligation(s) during your

absence, Peace Corps requires a notarized letter from that person affirming their
commitment to make thos.e payments.

OMB #0420-0005
13. Intelligence Activities and Organizations
It has been the Peace Corps' longstanding policy to exclude from

Peace Corps Volunteer service and Peace Corps employment, in
accordance with Peace Corps Manual Section 611, any persons who
have engaged in intelligence activity or related work or who have been
employed by or connected with an intelligence agency. This policy has
been reaffirmed by each successive administration.
Trle policy is founded on the premise that it is crucial to the Peace

Corps in carrying out its mission that there be a complete and total
separation of Peace Corps from the intelligence activities of the United
States government, both in reality and appearance. Any semblance of
a connection between Peace Corps and the intelligence community
would seriously compromise the ability of the Peace Corps to develop
and maintain the trust and confidence of the people of the host
countries. Serious doubts about an applicant's connection with
intelligence activities are to be resolved in favor of exclusion.
"Intelligence Activity" includes any activities or specialized training

involVing or related to the clandestine collection of information, or the
analysis or dissemination of such information, intended for use by the
United States government in formulating or implementing political or
military policy in regard to other countries. The term "intelligence
activity" includes any involvement in covert actions designed to
influence events in foreign countries.
Persons currently or formerly employed by the Central Intelligence

Agency shall be permanently ineligible for Peace Corps Volunteer
service. Other individuals who have not been employed by the Central
Intelligence Agency but whose background or work history discloses a
substantial connection with that agency may be disqualified as well.
In addition to employment with an intelligence agency or division thereof, applicants

may be disqualified for service because their background or history discloses a
substantial connection with an intelligence activity or related work other than
through employment. Even family relationships to an employee of an intelligence
agency may be considered a disqualifying connection.
Depending upon the nature of an applicant's involvement in or relationship to

intelligence activities or agencies, the duration of disqualification may range from a
permanent disqualification, disqualification up to ten years or disqualification for ten
years or more. Applicants are also advised that service as a Peace Corps Volunteer

OMB #0420-0005
may result in disqualification from employment with intelligence agencies of the U.S.
Government for periods following service as a Volunteer.
In some cases, employment or association with certain intelligence activities or

agencies will result in Peace Corps instructing you to contact those agencies who will
coordinate with Peace Corps, as necessary and appropriate, to assist Peace Corps in
rendering a final decision on your application.
Based upon the preceding, please answer the following questions:

A. Have you or a family member ever been associated with intelligence
activities of any agency of the U.S. government or any other government?
_Yes_No
B. Are you currently applying for employment with any intelligence agency or
other organization associated with intelligence activities? _Yes _No
If yes, you will be required to withdraw all applications for employment with
intelligence agencies after accepting an invitation to serve in the Peace
Corps and supply the Peace Corps with a copy of the letter to each agency
requesting the withdrawal of your application.
4. Military Status
A. Are you now a member of the ROTC, National Guard, or Reserves? _Yes
_No
If yes, how will you fulfill your
obligation? _
B. Are you currently serving or have you ever served in the U.S. Armed Forces?
_Yes_No
If yes, complete the following:

Branch _ Serial/File
number _
Highest rank held Dates of service:
from to _
Type of discharge _
C. If your discharge was other than honorable, explain the circumstances in

detail on a separate sheet of paper and attach to this page.
Note: If you are currently in the Inactive Ready Reserves (IRR) or expect to
transfer to IRR status, you will be required to prOVide proof of IRR status.
15. Marital Status (check all that apply, and fill in applicable information)
1. Single (never married)

2. Planning to marry within one year
Expected date of marriage: _

OMB #0420-0005
3. Married-planning to serve with spouse
Date of marriage: _
4. Married - planning to serve without spouse
Name of spouse: _
5. Widowed
6. Divorced or legally separated
*Each individual's official Peace Corps documents, such as passport, host country
work visa, and plane tickets must all be in the same name. If your marriage plans
involve a name change, note that legal procedures can take several weeks to provide
confirmations of name changes; therefore wedding dates should be planned well
before the anticipated date of entering the Peace Corps. For newlyweds. the Peace
Corps must have a marriage certificate and any name change confirmations at least
six months prior to your listed availability date (Item 2 of the Volunteer Application).
If you are married, a copy of your marriage certificate is required with your
appl ication.
If you are planning to serve with your spouse, please submit your applications
together. Indicate name and social security number of spouse or fiance:
First Name Middle, Last _

Social Security Number _
If you are divorced, you must attach separately the name(s) of all former spouse(s),
the date(s) of divorcees), separation, or death of a divorced spouse, and you must
submit with your application a copy of each divorce decree, in English, regardless of
when or where, including other countries, the divorce took place.
*If a former divorced spouse is deceased, it is not necessary to submit a final divorce
decree.
Please note that a married Applicants planning to serve without his/her

spouse will be required by the Peace Corps to provide a notarized letter
from the spouse acknowledging awareness of their application.
16. Dependents
A. Are any persons partially or totally dependent upon you for support whether or
not they are living with you? (Yes/No) (If you answer NO, please skip to item
17)
B. List all children under age 18, whether or not they are dependent upon you for
financial support.
Name of Child Address Date of Birth Dependent? (Yes/No)
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _(Yes/No)
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _(Yes/No)
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _(Yes/No)

OMB #0420-0005
C. List all dependents not listed above for whom you have support obligations.
Name of dependent Address Relationship
D. Please explain how you will continue to meet your support obligations while
serving without salary as a Volunteer.
Please note that the Peace Corps requires a notarized letter from the person
assuming responsibility for your dependent(s).
17. Job Preferences

List the work assignments in which you have an interest. (Assignments are
listed on the Peace Corps Website and in the Peace Corps catalogue.)
1.
2. _
3. _
18. Post-Secondary Education

Attach a copy of transcripts from all schools attended since high school (an
unofficial copy is acceptable). Please list all schools attended.
Type of Date
From To degree, rec'd or
Name of School, City and State Major Minor Mo/Yr Mo/Yr diploma expected
or certificate
19. Language Skills
Many assignments require previous language study. Please select the answer
that most closely describes your formal and/or informal language experience
you will have the opportunity to discuss your language skills in more detail
during the interview process. Only academic credit or informal acquisition
gained within the past 10 years will be accepted.

OMB #0420-0005
Spanish
High School
Total number of years taken in High School Zero 1 234
Highest course level completed in High School I II III IV
College
Total number of semesters completed in college Zero 1 2 3 4 5 6 7 8
Total number of quarters completed in college Zero 1 2 3 4 5 6 7 8

9 10 1112
Highest level course completed in college I II III IV V VI
Graduate School
Total number of semesters completed Zero 1 234 56
Total number of quarters completed Zero 1 2 3 4 5 6 7 8

9
Highest level course completed in graduate schools Zero 1 2 34 5 6 7 8

9
Study Abroad/Field Experience/Non-Academic Experience/Spoken at

Home/other accredited organization
Please Explain:
From (mm/yyyy) To (mm/yyyy)
French
High School

OMB #0420-0005
College
9 10 11 12
Graduate School
Total number of semesters completed Zero 1 23456

9
Highest level completed in graduate school Zero 1 2 3 4 5 6 7 8

9

Home/ other accredited organization
Please Explain:
From (mm/yyyy) To (mm/yyyy)
Other:
High School
College

9 10 11 12

OMB #0420-0005
Graduate School
Total number of semesters completed Zero 1 2345 6

9
Highest level completed in graduate school Zero 1 2 3 4 5 6 7 8

9

Home/other accredited organization
Please Explain:
From (mm/yyyy) To (mmjyyyy)
20. Licenses/Certificates
Are you or will you soon be a certified teacher? _Yes _No
Subject and grade

level _
List other job-related licenses or certificates such as nursing, CPR, and skilled
trades rankings including journeyman status, that you have or will have before
entering the Peace Corps. Include a photocopy of each current
license/certificate.
Expiration State or other
License or Certificate Date Licensing Agency
1. _
2. _
3. _
4. _
21. Employment History

Please complete this section and attach a copy of a current resume.
Starting with your most recent experience, please list at least ten years of your
employment history. Include any self-employment and full-or part-time paid
employment. Attach information separately if additional space is needed.

OM B #0420-0005
A. Current Employer
City/State
From (Mo/Yr) to (Mo/Yr)
Your title
--~
Duties/Achievements:
Hours per week

Name of supervisor
Phone number
Email address
May we contact your current employer? _Yes _No
B. Employer
City/State
Your title
Hours per week
Name of supervisor
Phone number
Email address
May we contact your former employer? _Yes _No
Reason for leaving
C. Employer
City/State
Your title
Hou rs per week
Name of supervisor
Phone number
Email address
Reason for leaving
D. Employer
City/State
Your title

OMB #0420-0005
Hou rs per week
Name of supervisor
Phone number
Email address
Reason for leaVing
E. Employer
City/State
From (l"1o/Yr) to (Mo/Yr)
Your title
Hours per week
Name of supervisor
Phone number
Email address
Reason for leaVing
F. Employer
City/State
Your title
Hours per week
Name of supervisor
Phone number
Email address
Reason for leaving
22. Time Gaps

Give specific dates and activities for each period of time greater than three
months not otherwise accounted for by employment, school, military, etc.
23. Community/Volunteer Activities

Peace Corps assignments require applicants to have leadership ability,
creativity, initiative, and a willingness to work with others. Please describe your
community, volunteer, or organizational work that demonstrates the following
skills or abilities:
• Initiating or carrying out activities;
• Planning activities involving others;
• Organizing others to participate in activities or to perform tasks;
OMB #0420-0005
• Motivating others to get and stay involved; or

• Leading, supervising, or managing others.
List your most recent activity first. Do not include experiences already listed in
employment history. Photocopy this page if additional sheets are necessary.
A. Organization
Position held
Hours per week
Name of supervisor
Phone number
Email address
Duties/ach ievements
B. Organization
Position held
Hours per week
Name of supervisor
Phone number
Email address
Duties/achievements
C. Organization
Position held
Hou rs per week
Name of supervisor
Phone number
Email address
Duties/achievements
D. Organization
Position held
Hou rs per week
Name of supervisor
Phone number
Email address
Duties/ach ievements
24. Preferences
The Peace Corps mission supports the needs of underdeveloped communities in
the world and honors the requests of host countries in providing Volunteers

OMB #0420-0005
where they are needed most. Your preferences are important to us in the
instances where we may be able to accommodate them.
Which best describes your interest in Volunteering with the Peace Corps (please
check one):
_ I am willing to go anywhere and do anything as needed.
__ I am willing to go anywhere, but wish to use a specific skill(s).
__ I wish to go to a particular geographic region, but will do anything needed.
_ I wish to go to a particular geographic region and use a specific skill(s) ..
Please indicate your geographic interests:
_No preference
_Sub-Saharan Africa _ North Africa/Middle East
_Eastern/Central Europe __ Central/South America
_Asia __Central Asia _Pacific Islands Caribbean
Briefly explain any preferences:
Indicate countries in which you would not want to work and explain why:
Please note that the Peace Corps does not place Volunteers in countries where
you may have family or other potential conflicts of interest. In what other
countries do you have family members?
25. Practical Experience

Experience gained from hobbies, volunteer activities, and part-time or summer
jobs may help you qualify for Peace Corps service. Listed below are a number of
skill areas. In the blocks below, please describe significant experiences you have
had in one or more of these areas. If you have described an experience
elsewhere in the application, it is not necessary to repeat the information here.
Business
Accounting/Bookkeeping
Business Management
Business Training
Cooperatives/Credit Unions
Fund-raising
Marketing
Volunteering with or working for non-profits

OMB #0420-0005
Engineering Management
Education/Teaching
Adult Education
Business Education
English/ESL/TEFL Tutoring
Art/Drama
Library Experience
Sports/Physical Education
Agriculture and Environment
Beekeeping
Environmental Education/
Conservation
Farming (after age 13)
Fisheries
4-H/FFA/FHA
Forestry/Greenhouse/Nursery
Parks/Wildlife
Vegetable Gardening
Agricultural Engineering
Health and Social Services
Health Outreach
Home Economics
Social Work/Counseling
Youth Work/Coaching
Long-term Assisted Care Provider
Skilled Trades
Auto/Diesel Mechanics
Construction
Electricity
Masonry
Meta Iworki ng
Plumbing
Vocational Education
Woodworking
Other
Com puter Science
Computer Literacy
Electrical/ Mechanical!Chemical Engineering
Specific activity: From (Mo/Yr) to (Mo/Yr)Hours per week
Brief description of experience
PC -1502 (Revised 6/02) 21 (All Previous editions are obsolete)

OMB #0420-0005
26. Cross-cultural Experience

Peace Corps Volunteers must be open to ideas and cultures different from their
own and may need to modify their appearance or behavior appropriately. Give
an example (between 150-500 words) of a significant experience that illustrates
your ability to adapt in an unfamiliar environment. Please highlight the skills you
used and the perspectives you gained. You may draw from experiences in your
work, school, or community in the U.S. or abroad. Please list the date(s) of your
experience.
27. Motivation Statement

Peace Corps service presents major physical, emotional, and intellectual
challenges. You have prOVided information on 'how you qualify for Peace Corps
service elsewhere in the application. In the space below, please provide a
statement (between 150-500 words) that includes:
• Your reasons for wanting to serve as a Peace Corps Volunteer

• How these reasons are related to your past experiences and life goals.
28. Certification
Please sign below and return this application to the regional office serving your
state. See back of application for addresses.
I CERTIFY that all of the statements made on all pages of this application,
including attachments, are true, correct, and complete to the best of my
knowledge, and are made in good faith. I understand that any misleading,
inaccurate, or incomplete information may be cause for disqualification or
termination from Peace Corps service. In addition, any intentionally false
statement may be subject to fines and imprisonment pursuant to 18 U.S.C. §
1001.
Signature Date

OMB #0420-0005
ATTENTION: PLEASE MAKE A COpy OF THIS

APPLICATION AND ALL ATTACHMENTS FOR
YOUR RECORDS
Survey Questions for Applicants
The question below is based on a four point scale, with four being the highest
rating.
• To what extent are you finding the following information about Peace
Corps helpful:
o website
o printed materials .
o your recruiter
o other

OMB #0420-0005
PRIVACY ACT AND PAPERWORK REDUCTION NOTICE - PEACE CORPS
APPLICATION
The Peace Corps, an agency of the federal government, is required by the

Privacy Act of 1974 (5 U.S.C. 552a) to advise you of the following information
regarding this application. The Privacy Act addresses the federal government's
use of certain personal information in agency files.
A. This application is authorized by the Peace Corps Act (22 U.S.C. 2501 et
seq.).
B. The principal purpose for which the information provided will be used is to
evaluate your suitability and qualifications to serve in a Peace Corps full-time
volunteer program.
C. Information in this application may routinely be disclosed as follows:
• To Peace Corps staff and contractors who have a need for the
information in performance of their duties;
• To host country officials for the purposes of obtaining visas and
determining program placement;
• To your family or next-of-kin so that you may be located in case of
emergency;
• In compelling circumstances affecting your health and safety;
• To Congressional offices in response to an inquiry made at your
request, or to Congress as requested;
• To a U.S. Ambassador or designee in a country where the Peace
Corps serves when the information is needed to perform an official
responsibility, to respond to official inquiries and deal with in
country situations that are within the scope of the Ambassador's
responsibility;
• As required under the Freedom of Information Act;
• To a court or other judicial body as appropriate;
• To the Department of Treasury and other federal agencies for use
in connection with support payments, tax matters and Social
Security;
• To verify active or former Volunteer service;
• In the case of United Nations Volunteers, to appropriate U.N.
officials;
• To law enforcement agencies as appropriate;
• As necessary to obtain information relevant to a security clearance;
• To federal agencies having a need to verify Volunteer eligibility for
federal employment;
• To the U.S. Office of Management and Budget in connection with
private relief legislation;

OMB #0420-0005
• To the Department of Justice and others for litigation purposes;

• To the National Archives and Records Administration for records
retention and records management inspections;
• To the U.S. Office of Personnel Management in connection with
their evaluation and oversight of federal personnel management;
• To the Bureau of the Census for census purposes;
• Without personal identifiers, for statistical purposes;
• To the Comptroller General in the performance of the duties of the
Government Accountability Office.
D. The completion of this form is voluntary. However, the failure to do so will

result in the Peace Corps being unable to assess your qualifications and result in
non-selection for the volunteer program for which you have applied.
E. The Peace Corps estimates that it will take 8 hours to complete this
form. Send comments about this form to Peace Corps, Paperwork Reduction
Project, 1111 20 th Street, NW, Washington, DC 20526. The Peace Corps may
not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. OMS control
number: 0420-0005 Continuous use form.

Vol •
. j
;
ap liea 1.0
'-------------------------'
:
;
f
;
," : .'. "
Vvww:; pecaceC017.ps.gp.,,:
; - tlJ' - ft~nn:. '.'''''''-:.''. n"r':o-n'
Instructions
•
Thank you for your interest in serving as a Peace Corps Volunteer. Should you become a Peace Corps
Volunteer, you will be undertaking an exciting and life-changing experience.
The Peace Corps needs Volunteers with a wide variety of skills. These skills can be acquired through
education, professional work experience, volunteer experience, or hobbies. This application is de
signed to give you the best opportunity to tell us about all of your skills.
To be eligible for Peace Corps service, you must:

• be a citizen of the United States;
• be at least 18 years of age; and
• meet the medical, legal, and security requirements.
Assignments are filled based on requests from Peace Corps host countries for Volunteers with specific
skills. Complete the questions as fully as possible to give yourself the best chance for consideration.
Married couples are eligible, but both spouses must qualify and serve as Volunteers. Each spouse
should complete a separate application, but the applications should be submitted together. We are
unable to place families with dependent 'children.
We recommend that you review the application before you begin. Note that:
• the pages can be removed for use in a typewriter; .
• questions 19 (Employment History), 21 (Community/Volunteer Activities)
and 23 (Practical Experience) can be duplicated if additional blocks are needed;
• answers for questions 24 (Cross-Cultural Experience) and 25 (Motivation Statement)
can be prepared on a computer and attached; and
• separated pages should be reassembled in sequential order.
Included with this packet is a health status review form. After completing the form, place it in the
medical information envelope and submit it with the application packet. To serve as a Peace Corps
Volunteer, you must be medically and dentally screened and qualified. If you are nominated for Peace
Corps service, you will receive additional forms and instructions for completing your medical and dental
exarninations.
To apply, send your completed application and health status review form, along with one copy of a
current resume and copies of transcripts from all schools attended since high school, in the envelope
provided. We look forward to receiving your application. You will hear from your Regional Office shortly!
If you have questions, please contact the Peace Corps Regional Office serving your state
(see back cover). TDD services are available.
IMPORTANT
The Peace Corps does not discriminate based on race, color, national origin, religion, age, sex, handicap, .
political affiliation, or sexual orientation. Anyone who feels he or she has been discriminated against should
contact the Peace Corps American Diversity Office, Washington, D.C. 20526.
For Office Use Only

EC Lang 1 Exp Lang 2 Exp
Ed level College 1 Degree 1 Major 1 Minor 1
Grad date 1 College 2 Degree 2 Major 2 Grad date 2
College 3 Degree 3 Major 3 Grad Date 3 Maritai
Spouse full name SpouseSSN Dependents _ _ _
Source Recruiter Completed by Date

OMB # 0420-0005
Peace Corps Volunteer Application

1. Name .'
2. Social Security Number 3. The earliest date you will be available

for Peace Corps service
You will be considered for assignments beginning
after this date. Please notify your recruiter if this
date changes.
4. Date of Birth
--_/_-_/_--
Month Day
--_./_-_/_--
Month Day
5. Gender o Female o Male
6. Have you previously If yes, give dates and location:
A Submitted a Peace Corps application? 0 Yes 0 No

B. Participated in Peace Corps training? 0 Yes 0 No
C. Served as a Peace Corps Volunteer? 0 Yes 0 No
7. Are you applying to the Master's International Program? DYes o No

School _
8. Peace Corps Volunteers must be U.S. Citizens
A. Are you a U.S. citizen? 0 Yes 0 No B. Certificate of Naturalization number if you

are a naturalized citizen, or expected date
If yes, give place of birth. of naturalization:
9. Address
A Current Mailing Address B. Name and address of person through

All information will be sent to this address until whom you can always be reached
you notify the Peace Corps of a change of address.
Number and Street Apt. No. First name Last name Relationship
City/State/Zip Number and Street Apt. No.
Home Phone City/State/Zip

( )
Work Phone Home Phone
E-mail address (if available) Work Phone
C. Do you expect to move in the next 12 months? 0 Yes 0 No If yes, when? _ _/ - _ /_ _

Month Day Year
Please notify your recruiter of any change in either your address
or that of the person through whom you can be reached.
10. Intelligence Activities and Organizations
Intelligence activity is defined as the clandestine collection; dissemination, or analysis of
information intended for use by any government in formulating or implementing political or
military policy in regard to other countries, and/or covert activities of any kind designed to
influence events in foreign countries.
Persons who have been employed by an intelligence agency or otherwise associated with
intelligence activities are ineligible to serve as Volunteers in most circumstances. This
exclusionary policy is one aspect of the broader long-standing policy of maintaining a
complete and total separation between the Peace Corps and the intelligence activities of the
U.S. Government. This separation is necessary to protect Volunteers' safety and to maintain
the trust and confidence of the people in the countries we serve.
Disqualifying Employment:
Persons who have been employed by the Central Intelligence Agency (CIA) in any capacity
are permanently ineligible for Pe'ace Corps service. This exclusion applies to persons who
served as interns, volunteers, or contractors for the CIA, regardless of the duties.
Persons who have served in other agencies or divisions of agencies that are substantially
involved in intelligence activities are similarly ineligible regardless of the specific duties they
may have performed. The National Security Agency, the Defense Intelligence Agency, and the
Defense Mapping Agency are among the agencies covered by the policy. However unlike the I
permanent disqualification that affects former CIA employees, former employees of these
agencies may be eligible for Peace Corps service after ten years from their last date of
employment with the agency.
Other Disqualifying Factors:

Persons whose work history involves a substantial connection with an intelligence agency or
activity, through employment or otherwise, are ineligible for Peace Corps service for at least
ten years from the date of their last connection with the activity.
If you have applied for employment with any intelligence agencies, you will be required to
withdraw that application before entering Peace Corps service and to supply the Peace Corps
with a copy of the letter to the agency requesting the withdrawal.
Individuals with close family relations who have engaged in intelligence activities may also
be ineligible for Peace Corps service. If you have been associated, even through a close family
member, with the CIA or other intelligence agencies, or otherwise with an intelligence
activity, you or the relevant family member should consult with the General Counsel of the
respective agency who will, in turn, consult with the Peace Corps General Counsel.
A. Are you now or have you ever been associated with

intelligence activities of any agency of the U.S. government OYes ONo
or any other government?
If yes, provide details including dates and agency or division for wpich the work
was performed and/or the nature olthe association. If military, give your MOS
number code or designator, and any service schools attended, on a separate
sheet of paper and attach to this page.
B. Are you currently applying for employment with any intelligence

agency or other organization associated with intelligence activities? 0 Yes 0 No
11. Legal and Financial Infonnation
Take special.note that if you fail to disclose any prior or pending offenses or any unsatisfied
financial obligations, the Peace Corps may delay your departure for training, revoke your
invitation to serve, or disqualify you from Prace Corps service.
A. Prior or Pending Offenses:

If invited to serve in the Peace Corps, you must undergo, at a minimum, a National Agency
Check (NAC) background investigation to help determine your legal eligibility for service.
The necessary forms and fingerprint charts will be sent to you later.
1) Have you ever been convicted of, or pled guilty to, any offense in a civilian or
military court or tribunal, or have you been subjected to any disciplinary
action by a military court or tribunal? DYes DNo
Include misdemeanors, felonies, "open container" violations, and DUIIDWIs, but do
not include traffic violations for which the entire penalty was a fine of $200 or less,
or non-felony offenses that occurred before your 18th birthday.
2) Are any charges (for any offense, including traffic offenses), civil suits, or
judgments outstanding against you? DYes DNo
If you answered "yes" to either question, attach a separate sheet with your name and a complete expla
nation of each arrest, suit, judgment, disciplinary action, and pending charge, including the circumstances
and nature of the charge or suit, its current status or disposition, and any sentence or fine imposed.
B. Financial Obligations:
Before you can serve in the Peace Corps, you must provide documentation establishing that you
have made arrangements satisfactory to your lender(s) todefer, pay, or otherwise fulfill your
financial obligations. Should you be recommended for an assignment, you will be required to
submit this documentation to the Peace Corps Placement Unit. The Peace Corps may also obtain
a credit report on you.
1) As of the date of this application, do you have any student loans? 0 Yes 0 No
If yes, please provide the following information (attach a separate sheet if necessary):
Type of Student Loan Amount
2) As of the date of this application, do your other financial obligations

(including, but not limited to, a mortgage, consumer debt, or credit
card debt) total more than $5,000? 0 Yes 0 No
Type of Financial Obligation Amount
3) Do you have any financial obligations-regardless of the amount, and

including those listed above--that will not be paid in full, deferred, or
otherwise fulfilled to your lender(s)' satisfaction prior to your departure
for Peace Cotps training? . DYes DNa
If you have any questions about these legal and financial issues that your recruiter cannot answer,
you may call the Peace Corps Legal Eligibility Office at (800) 424-8580, ext. 1845, for assistance.
12. Military Status
A. Are you now a member of the ROTC, National Guard; or Reserves? DYes DNo
If yes, how will you fulfill your obligation?' _
B. Are you currently serving or have you ever served in the

U.S. Anned Forces? DYes DNo
Branch _ SeriaVFilenumber __
Highest rank held _ Dates of service: from to _
Type of discharge _
C. If your discharge was other than honorable, explain the circumstances in detail on
a separate sheet of paper and attach to this page.
13. Marital Status (check all that apply)

You will be asked to submit a copy of your marriage certificate and/or final divorce decree(s)
and all related documents if you receive a Peace Corps nomination.
1. D Single (never married) 4. 0 Married-planning to serve without spouse

(Name of spouse: _
2. 0 Planning to marry within one year
(expected date of marriage: _ 5.0 Widowed
3. 0 Married-planning to serve with spouse 6. 0 Divorced or legally separated _

(date of marriage: _
If you are planning to serve with your spouse, please submit your applications together.
Indicate name and social security number of spouse (fiancelfiancee):
Name
Social Security Number _
List the name(s) of all former spouse(s) as well as the year(s) of divorce,
separation, or death:
14. Dependents
A. Are any persons partially or totally dependent upon you for support
whether or not they are living with you? (If you answer no, skip to #15.) 0 Yes 0 No
B. List all children under age 18, whether or not they are dependent
upon you for financial support.
Name of child Address Age Dependent?
DYes DNa
DYes DNa
DYes 0 No
DYes DNa
c. List all dependents not listed above for whom you have support obligations.
Name of dependent Address Relationship
D. Do you have adequate means to continue to meet your support

obligations while serving without salary as a Volunteer? DYes DNa
If yes, please specify what arrangements would be made on a separate sheet
of paper and attach to this page.
15. Job Preferences

List the work assignments in which you have an interest.
(Assignments are listed in the Peace Corps catalogue.)
1.
2.
3.
16. Education
Attach a copy of transcripts from all schools attended since high school (an official copy is
not necessary). Beginning with high school, list all schools attended.
Type of Date
From To degree or rec'd or
Name of School, City and State Major Minor Mo/Yr Mo/Yr diploma expected
17. Language Skills

SOfie assignments require previous language study. Please indicate your number of years of
experience in learning and speaking languages other than English within the past ten years.
# Years Studied Spoken Abroad/Spoken at Home
High From To
Language School College Other Place Mo/Yr Mo/Yr
Spanish
French
Other:
Other:
18. Licenses/Certificates
Are you or will you be a state-certified teacher? DYes DNa
Subject and grade level _
List other job-related licenses or certificates such as nursing, CPR, and skilled trades rankings
including journeyman status, that you have or will have before entering the Peace Corps.
Include a photocopy of each current license/certificate.
1.
2.
3.
4.
19. Employment History
Attach to this page one copy of a current resume.
Please complete this section starting with your most recent experience. Go back at least
ten years. Include any self-employment, home management, and full- or part-time paid
employment. Photocopy this page if additional sheets are necessary.
A. Current Employer D. Employer
City/State City/State
From (MolYr) to (MolYr) From (MolYr) to (MaIYr)
Your title Your title
Hours per week Hours per week
Name of supervisor Name of supervisor
May we contact your Phone number

current employer? DYes DNa
Reason for leaving
B. Employer
E. Employer
City/State
City/State
From (MolYr) to (MaIYr)
From (MolYr) to (Ma/Yr)
Your title
Your title
Hours per week
Hours per week
Name of supervisor
Name of supervisor
Phone number
Phone number
Reason for leaving
Reason for leaving
C. Employer
F. Employer
City/State
City/State
From (MolYr) to (MolYI)
From (MalYI) to (Mo/Yr)
Your title
Your title
Hours per week
Hours per week
Name of supervisor
Name of supervisor
Phone number
Phone number
Reason for leaving
Reason for leaving
20. Time Gaps

Give specific dates and activities for each period of time greater than three months not
otherwise accounted for by employment, school, military, etc.
21. Community/Volunteer Activities
Peace Corps assignments require applicants with leadership ability, creativity, initiative and I
a willingness to work with others. Please describe your community, volunteer, or organizational
work that demonstrates the following skills or abilities:
• Organizing others to participate in .activities or to perform tasks;
List your most recent activity first. Do not include experiences already listed in employment
history. Photocopy this page if additional sheets are necessary.
A. Organization C. Organization
Position held Position held

From (Ma/YI) to (MalYI) From (MalYI) to (Ma/YI)
Phone· number Phone number
Duties/achievements Duties/achievements
B. Organization D. Organization
Position held Position held

From (MolYr) to (MO/YI) From (Ma/YI) to (Ma/YI)
Phone number Phone number
Duties/achievements Duties/achievements
22. Geographic Preference

Where a Volunteer is placed depends primarily upon how well the individual's experience
meets the requirements of a specific assignment. We ask you to be flexible about your
geographic area of assignment. However, if you do have preferences for particular regions
of the world, indicate them below:
o No preference o Africa o North Africa/Middle East o Eastern Europe/Central Asia
o Asia o Pacific Islands o Caribbean o Latin America
Briefly eXPlain., any preferences: _
Indicate countries in which you would not want to work and explain: _
23. Practical Experience
Experience gained from hobbies, volunteer activities, and part-time or summer jobs may
help you qualify for Peace Corps service. Listed below are a number of skill areas. In the
blocks below please describe significant eX1?eriences you have had in one or more of these
I
areas. If you have described an experience elsewhere in the application, it is not necessary
to repeat the information here.
Business Agriculture and Environment Skilled Trades
Accounting/Bookkeeping Beekeeping Auto/Diesel Mechanics
Business Management Environmental Education/ Construction
Business Training Conservation
Electricity
Cooperatives/Credit Unions Fanaring(afterage13)
Masonry
Fund-raising Fisheries
Metalworking
Marketing 4-H/FFA/FHA
Plumbing
Volunteering with or Forestry/Greenhouse/Nursery
Vocational Education
working for non-profits Parks/Wildlife
Woodworking
Vegetable Gardening
Education/Teaching Other
Adult Education Health and Social Services Computer Science
Business Education Health Outreach Computer Literacy
English/ESL/TEFL Tutoring Home Economics
Art/Drama Social Work/Counseling
Library Experience Youth Work/Coaching/Sports
Specific activity: From (MolYr) to (MolYr) Hours per week
Specific activity: From (MolYr) to (MalYI) Hours per week

24. Cross-cultural Experience
Peace Corps Volunteers must be open to ideas and cultures different from their own. Give
an example of a significant experience that illustrates your ability to adapt cross-culturally.
You may draw from experiences in your wprk, school, or community in the U.S. or abroad.
Please include the circumstances of the experience and dates.
25. Motivation Statement
Peace Corps service presents major physical, emotional, and intellectual challenges. You have
provided information on how you qualify for Peace cOrps service elsewhere in the application.
In the space below, please provide a statemEint (between 150-500 words) that includes:
• Your reasons for wanting to serve as a Peace Corps Volunteer; and
26. Certification
Please sign below and return this application to the Regional Office serving your state.
See back of application for addresses.
I CERTIFY that all of the statements made on all pages of this application, including attachments,
are true, correct, and complete to the best of my knowledge and are made in good faith. I understand
that any misleading, inaccurate, or incomplete information may be cause for disqualification or
termination. In addition, any intentionally false statement may be subject to criminal sanctions
pursuant to 18 U.S.C. § 1001.
Signature Date
Request for Racial and Ethnic Data

This information is voluntary. Your response will not affect consideration of your application.
By providing this information you will assist us in assuring that the Peace Corps is
administered in a nondiscriminatory manner and reflects the diversity ofthe United States.
The information requested in this section is covered by the Privacy Act Notice on the
following page.
Please check the box next' to the classification that applies to you.
o Black, not of Hispanic origin (1)
o Hispanic (a person of Mexican, Puerto Rican, Cuban, Central or
South American, or other Spanish culture or origin, regardless of race) (2)
o American Indian or Alaskan Native (a person having origins in any of
the original peoples of North America) (3)
o Asian or Pacific Islander (a person having origins in any of the original

peoples of the Far East, Southeast Asia, the Indian subcontinent, or the
Pacific Islands. This area includes, for example, China, India, Japan,
Korea, the Philippines, Samoa, and Vietnam.) (4)
o White, not of Hispanic origin (having origins in any of the original peoples
of Europe, North Africa, or the Middle East) (7)
o More than one of the above (comment if you wish) (5)

Privacy Act and Pape"'l0rk Reduction Notice
The Peace Corps, an agency of the Federal Government, is required by provisions of the Privacy Act of 1974
(5 U.S.C. 552a) to advise you of the following information regarding this application:
A. This application is authorized by provisions of the Peace Corps Act (22 U.S.C. 2501, et seq.), which
authorize the collection of information regarding the suitability and qualifications of applicants.
B. The principal purpose for which the information provided will be used is to evaluate your suitability and
qualifications to serve in a Peace Corps full-time volunteer program.
C. Information in this application may routinely be disclosed as follows:
1. to host country agencies for the purpose of determining placement, obtaining visas, and other
program-related matters;
2. to police or judicial authorities where appropriate;
3. to the Treasury and other Federal agencies for use in connection with support payments and Social
Security and Federal Income tax matters;
4. to the Office of Personnel Management, other Federal agencies, and others, if necessary, for the
purpose of a background suitability investigation;
5. to other Federal agencies having an interest in employment of the applicant or Volunteer, proVided that
except for information required for authorized security clearances, information provided will be limited
to dates of service and a standard description of service;
6. to a court or other appropriate tribunal upon subpoena or other request;
7. to a member of Congress upon request indicating that such member has been requested by an
individual about whom the record is maintained to obtain such information;
8. a source for management information or preparation for statistical reports (without personal informa
tion);
9. to the National Archives and Records Administration, GSA, in authorized management inspections;
10. when required under provisions of the Freedom of Information Act (5 U.S.C. 552) and Privacy Act (5
U.SC. 552a);
11. to the Bureau of the Census for the purposes of planning or carrying out a census surveyor related
activity pursuant to the provisions of Title 13, U.S. Code;
12. to Peace Corps personnel who have a need for the information in the performance of their duties;
13. to the Volunteer's family members in emergency situations; and
14. in the case of United Nations Volunteers, to appropriate UN officials.
D. The completion of this application is voluntary; however, failure to provide information requested may
result in the Peace Corps' inability to assess the qualifications of an applicant and result in non-selection
for the volunteer program for which that applicant has applied.
E. The Peace Corps estimates that it will take 8 hours to complete this form. Send comments on this form
to Peace Corps, Paperwork Reduction Project, Washington, DC 20526. OMB control number: 0420-0005.
The Peace Corps may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. Continuous use form.
[PEACE CORPS REGIONAL OFFICES '
Atlanta, Georgia Denver, Colorado San Francisco, California

(FL, GA, AL, MS, PR, SC, TN)
(CO, KS, NE, UT, WY)
(Northern CA, HI, NV)
Peace Corps Regional Office

100 Alabama Street

1999 Broadway
333 Market Street
Building #1924, Suite 2R70

Suite 2205
Suite 600
Atlanta, GA 30303-8702
Denver, CO 80202-3050
San Francisco, CA 94105-1914
(404) 562-3456
(303) 844-7020
(415) 977-8800
FAX: (404) 562-345S

FAX: (303) 844-7010
FAX: (415) 977-8803
atlinfo@peacecorps.gov
denver@peacecorps.gov
sfinfo@peacecorps.gov
Boston, Massachusetts Los Angeles, California Seattle, Washington

(MA, ME, NH, RI, VT)
(Southern CA, AZ)
(WA, AK, JD, MT, OR)

10 Causeway Street, Room 450

2361 Rosecrans Avenue
2001 Sixth Avenue
Boston, MA 02222-1099
Suite 155
Suite 1776
(617) 565-5555
EI Segundo, CA 90245
Seattle WA 98121-2522
FAX: (617) 565-5539

(310) 356-1100
(206) 553-5490
boston@peacecorps.gov
FAX: (310) 356-1125
FAX: (206) 553-2343
lainfo@peacecorps.gov192.9.100.10
seattle@peacecorps.gov
Chicago, Illinois
(IL, IN, KY, MI, MO, OH)
Minneapolis, Minnesota Washington, DC
(MN, IA, NO, SO, WI)
(DC, DE, MD, NC, VA, WV)
55 West Monroe Street

Suite 450
330 2nd Avenue, South, Suite 420
1525 Wilson Boulevard
Chicago, IL 60603-5001
Minneapolis, MN 55401-9802
Suite 100
(312) 353-4990
(612) 348-1480
Arlington, VA 22209
FAX: (312) 353-4192

FAX: (612) 348-1474
(703) 235-9191
chicago@peacecorps.gov
minneapolis@peacecorps.gov
FAX: (703) 235-9189
dcinfo@peacecorps.gov
Dallas, Texas New York, New York

(TX, AR, LA, NM, OK)
(NY, CT, NJ, PA, VI)
Headquarters
Paul D. Coverdell
207 S. Houston Street, Room 527
201 Varick Street
Peace Corps Headquarters
Dallas, TX 75202-4790
Suite 1025
1111 20th Street NW
(214) 253-5400
New York, NY 10014
Washington, DC 20526
FAX: (214) 767-5483

(212) 352-5440
dallas@peacecorps.gov
FAX: (212) 352-5441
nyinfo@peacecorps.gov
Call toll-free at (800) 424-8580 to be

connected to the office nearest you.
TDD Services are available.

Printed on recycled paper
OMB # 0420-0005
Peace (~OIl)S' llullteer \.})})licatioll
1. NAME
2. SOCIAL SECURITY NUMBER 3. THE EARLIEST DATE YOU WILL BE

AVAILABLE }'OR PEACE CORPS SERVICE
(You will be considered for assignments beginning after
this date. Please notify your recruiter if this date changes.)
____I / _
4. DATE O}' BffiTH Month Day Year
_ _-----'I 1 _
Month Day Year 5. GENDER o Female o Male
6. HAVE YOU PREVIOUSLY If yes, give dates and location:

A. Submitted a Peace Corps application? DYES o NO
B. Participated in Peace Corps training? DYES o NO
C. Served as a Peace Corps Volunteer? DYES o NO
7. ARE YOU ArPLYING TO THE MASTER'S INTERNATIONAL PROGRA.l\1? DYES o NO

SCHOOL
8. PEACE CORPS VOLUNTEERS MUST BE U.S. CITIZENS
A. Are you a U.S. citizen? 0 YES 0 NO B. Certificate of Naturalization number if you are a
If yes, give place of birth. naturalized citizen, or expected date of naturalization.
9. ADDRESS
A. Current Mailing Address. (All information B. Name and address of person through whom you
will be sent to this address until you notify can always be reached.
the Peace Corps of a change of address.)
Number and Street Apt. No. First Name Last Name Relationship
City/State/Zip Number and Street

( )
Home Phone City/State/Zip
( ) ( )
Work Phone Home Phone
( )
E-mail Address (if available) Work Phone
C. Do you expect to move in the next 1Z months? 0 YES 0 NO If yes, when? _ _/ / _

Please notify your recruiter of any change in either your address or Month Day Year
that of the person through whom you can be reached.
1
,
10. INTELLlu:.uNCE ACTI\'A..tIEs AND OR&.a:mZATIONb
Intelligence activity is defined as the clandestine collection, dissemination, or analysis of information intended tor use by any
government in formulating or implementing political or military policy in regard to other cGtmtries, and/or covert activities of any
kind designed to influence events in foreign countries.
Persons who have been employed by an intelligence agency or otherwise associated with intelligence activities are ineligible to
serve as Volunteers in most circumstances. This exclusionary policy is one aspect of the broader long-standing policy of
maintaining a complete and total separation between the Peace Corps and the intelligence activities ofthe U.S. Government.
This separation is necessary to protect Volunteers' safety and to maintain the trust and confidence of the people in the countries
we serve.
DisqualifYing Employment: Persons who have been employed by the Central Intelligence Agency (CIA) in any capacity are
permanently ineligible for Peace Corps service. This exclusion applies to persons who served as interns, volunteers, or
contractors for the CIA, regardless of the duties.
Persons who have served in other agencies or divisions of agencies that are substantially involved in intelligence activities are
similarly ineligible regardless of the specific duties they may have performed. The National Security Agency, the Defense
Intelligence Agency, and the Defense Mapping Agency are among the agencies covered by the policy. However, unlike the
permanent disquali£cation that affects former CIA employees, former employees ofthese agencies may be eligible for Peace
Corps service after ten years from their last date of employment with the agency.
Other DisqualifYing Factors: Persons whose work history involves a substantial connection with an intelligence agency or
activity, through employment or otherwise, are ineligible for Peace Corps service for at least ten years from the date of their last
connection with the activity.
If you have applied for employment with any intelligence agencies, you will be required to withdraw that application before
entering Peace Corps service and to supply the Peace Corps with a copy ofthe letter to the agency requesting the withdrawal.
Individuals with close family relations who have engaged in intelligence activities may also be ineligible for Peace Corps service.
If you have been associated, even through a close family member, with the CIA or other intelligence agencies, or otherwise with
an intelligence activity, you or the relevant family member should consult with the General Counsel of the respective agency
who will, in tum, consult with the Peace Corps General Counsel.
A. Are you now or have you ever been associated with intelligence activities
of any agency of the U.S. government or any other government? DYES o NO
Ifyes, provide details including dates and agency or division for which the work was performed and/or the
nature ofthe association. Ifmilitary, give your MOS number code or designator, and any service schools
attended, on a separate sheet ofpaper and attach to this page.
B. Are you currently applying for employment with any intelligence agency or other
organization associated with intelligence activities? DYES o NO
"'
11. LEGAL AND :F~ANCIAL IJI4~~ORnIATION
Take special note that if you fail to disclose any prior or pending offenses or any unsatisfied financial obligations,
the Peace Corps may delay your departure for training, revoke your invitation to serve, or disqualify you from
Peace Corps service.
A. PRIOR OR PENDING OFFENSES:
If invited to serve in the Peace Corps, you must undergo, at a minimum, a National Agency Check (NAC)
background investigation to help determine your legal eligibility for service. The necessary forms and fingerprint
charts will be sent to you later.
I) Have you ever been convicted of, or pled guilty to, any offense in a civilian or military court
or tribunal, or have you been subjected to any disciplinary action by a military court or tribunal?
(Include misdemeanors, ~elonies, "open container" violations, and DUIIDWIs, but do not
include traffic violations for which the entire penalty was a fine of $200 or less, or
non-felony offenses that occurred before your 18th birthday.) 0 YES o NO
2) Are any charges (for any offense, including traffic offenses), civil suits, or judiments
outstanding against you? DYES o NO
If you answered "yes" to either question, attach a separate sheet with your name and a complete explanation of each
arrest, suit, judgment, disciplinary action, and pending charge, including the circumstances and nature of the charge or
suit, its current status or disposition, and any sentence or fine imposed.
B. FINANCIAL OBLIGATIONS:
Before you can serve in the Peace Corps, you must provide documentation establishing that you have made arrange
ments satisfactory to your lender(s) to deter, pay, or otherwise fulfill your financial obligations. Should you be
recommended for an assignment, you will be required to submit this documentation to the Peace Corps Placement
Unit. The Peace Corps may also obtain a credit report on you.
1) As of the date of this application, do you have any student loans? DYES o NO
TYPE OF STUDENT LOAN AMOUNT
2) As of the date of this application, do your other financial obligations (including, but not
limited to, a mortgage, consumer debt, or credit card debt) total more than $5,0001 0 YES o NO
TYPE OF FINANCIAL OBLIGATION AMOUNT
3) Do you have any financial obligations -- regardless of the amount, and including
those listed above -- that will not be paid in full, deferred, or otherwise fulfilled to
your lender(s)' satisfaction prior to your departure for Peace Corps training? DYES o NO
If you have any questions about these legal and financial issues that your recruiter cannot answer, you may call the
Peace Corps Legal Eligibility Office at (800) 424·8580, ext. 1845,[or assistance.
!
... /
12. l\IILITARY STATUS
A. Are you now a member of the ROTC, National Guard, or Reserves? DYES D NO
If yes, how will you fulfill your obligation? _
B. Are you currently serving or have you ever served in the u.S. Armed Forces? DYES D NO·
If yes, complete the following: Branch _ SeriaVFile number _
Highest rank held Dates of service: From _ _ _ _ _ _ _ to
Type of discharge _
C. If your discharge was other than honorable, explain the circumstances in detail on a separate sheet of paper
and attach to this page.
13. l\IARITAL STATUS (check all that apply)
You will be asked to submit a copy of your marriage certificate and/or final divorce decreers) and all related documents if
you receive a Peace Corps nomination. .
1 D Single (never married) 4 D Married-planning to serve without spouse
2 D Planning to marry within one year Name of Spouse: _
(expected date of marriage: . 5 D Widowed

3 D Married-planning to serve with spouse 6 D Divorced or legally separated
(date of marriage: )
If you are planning to serve with your spouse, please submit your applications together. Indicate name and social
security number of spouse (fianCE/fiancee):
First Name Middle Last Name
Social Security Number
List the name(s) of all former spouse(s) as well as the year(s) of divorce, separation, or death:
)
14. DEPENDENTS
A. Are any persons partially or totally dependent upon you for support whether or
not they are living with you? (If you answer no, skip to'#IS.) DYES DNO
B. List all children under age IS, whether or not they are dependent upon you for financial support.
NAME OF CHILD ADDRESS AGE DEPENDENT?
DYES DNO
DYES DNO
DYES DNO
C. List all dependents not listed above for whom you have support obligations.
NAME OF DEPENDENT ADDRESS RELATIONSHIP
D. Do you have adequate means to continue to meet your support obligations while
serving without salary as a Volunteer? DYES DNO
If yes, please specify what arrangements would be made on a separate sheet ofpaper and attach to this page.
15. JOB PREII'ERENCES
List the work assignments in which you have an interest. (Assignments are listed in the Peace Corps catalogue.)
1. _
2. --' _
3. ~ _
16. EDUCATION
Attach a copy of transcripts from all schools attended since high school. (An official copy is not necessary.)
Beginning with high school, list all schools attended.' T ype 0 f
C
Date
From To degree or rec'd or
Name of School, City and State Major Minor mo/yr mo/yr diploma expected
17. LANGUAGE SKILLS

Some assignments require previous language study. Please indicate your number of years of experience in learning
and speaking languages other than English within the past ten years.
Language # Years Studied Spoken Abroad/Spoken at Home

From To
High College Other mol mol
School Place
yr yr
Spanish
French
Other:
Other:
18. LI(ENSES/CERTI}~ICATES
Are you or will you be a state-certified teacher? 0 YES o NO Subject and grade level _
List other job-related licenses or certificates such as nursing, CPR, and skilled trades rankings including journeyman
status, that you have or will have before entering the Peace Corps. Include a photocopy ofeach current license/
certificate.
1.
2.
3.
6
REFERENCE LABEL SHEET
,e e
References are an essential part of the Peace A Name and address of current job supervisor.
If you do not want the Peace Corps to contact this
Corps selection process. You will not be
person, list another employer or supervisor.
considered for Peace Corps service without the
references requested on this sheet. Please Applicant's Name _
choose references who best know your
A---:- _
qualifications for Peace Corps service and
Reference's Name Company
who will respond promptly to your request
for a reference. Address
Please review the following instructions before

City/State/ZIP
completing the labels on the right.
( J-----------
Phone Number
• Contact your references to verify
addresses and phone numbers. Please B. Name and address of volunteer work supervisor.
If you do not have a current or past volunteer work
stress the importance of returning supervisor, use a current or past work supervisor.
completed forms to you within seven
working days. Also inform your refer Applicant's Name _
ences that the Peace Corps may contact
B, _
them if follow-up is necessary. Reference's Name Company
Address
• Type or print your name and the name,
address, and phone number of each
City/State/ZIP
reference on labels A through C. The type
of reference required is described above ( J---------
each label. You may not use family Phone Number
members or persons with whom you C. Name and address of a personal acquaintance,
are romantically involved. If you have (e.g. , a friend, co-worker, or classmate) who best
knows your qualifications for Peace Corps service.
any questions regarding appropriate
references, please contact your Peace
Applicant's Name _
Corps Regional Office.
c, _
Reference's Name
• Return the completed label sheet, along
with your application and health status Address
review form, to the Peace Corps
Regional Office in the envelopes City/State/ZIP
provided. Please do not submit

( )------------
completed references with this Phone Number
application.
Form PM-03
(Revised 10/98)
19. El\IPLOYl\IENT HISTORY

Attach to this page one CQP.Y ora current resume.
Please complete this section starting with your most recent experience. Go back at least ten years. Include any self
employment} home management, and full or part-time paid employment. Photocopy this page if additional sheets
are necessary.
A. Current Employer D. Employer _

City/State _ City/State _
From (mo/yr) to (mo/yr) _ From (mo/yr) to (mo/yr) _
Your title _ _~ _ Your title _

Hours per week _ Hours per week _
Name of supervisor _ Name of supervisor _
Reason for leaving
May we contact your current employer? 0 YES 0 NO
B. Employer E. Employer
From (mo/yr) to (mo/yr) From (mo/yr) _ _ _ _ _ _to (mo/yr) _

Reason for leaving Reason for leaving
Co Employer }'. Employer

From (mo/yr) to (mo/yr) From (mo/yr) _ _ _ _ _ _to (mo/yr) _

Reason for leaving Reason for leaving
20. TIl\1E GAPS
Give specific dates and activities for each period of time greater than three months not otherwise accounted for by
employment, school, military,etc.
7
21. COl\Il\IUN~t Y/VOLUN'I11~R ACTIVITIEJ~
Peace Corps assignments require applicants with leadership ability, creativity, initiative, and a willingness to work
with others. Please describe your community, volunteer, or organizational work that demonstrates the following
skills or abilities:

• Organizing others to participate in activities or to perform tasks;
List your most recent activity first. Do not include experiences already listed in employment history. Photocopy
this page if additional sheets are necessary.
A. Organization C. Organization _
Position held _ Position held _
Hours per week Hours per week _

Name of supervisor _ Name of supervisor _
Duties/Achievements Duties/Achievements
B. Organization _ D. Organization _
Position held _ Position held _
Hours per week Hours per week _

Name of supervisor _ Name of supervisor
Phone number _ Phone number
Duties/Achievements Duties/Achievements
22. GEOGRAPHIC PRElfERENCE

Where a Volunteer is placed depends primarily upon how well the individual's experience meets the
requirements of a specific assignment. We ask you to be flexible about your geographic area of assignment.
However, if you do have preferences for particular regions of the world, indicate them below:
o No preference 0 Africa 0 North Africa/Middle East 0 Eastern Europe/Central Asia
o Asia 0 Pacific Islands 0 Caribbean 0 Latin America
Briefly explain any preferences: _
Indicate countries in which you would not want to work and explain: -----' _
(1, , ,~~,
23. PRAeTIeAL F..APERIENGE' - ~
Experience gained from hobbies, volunteer activities, and part-time or summer jobs may help you qualify for Peace
Corps service. Listed below are a number of skill areas. In the blocks below, please describe significant experiences
you have had in one or more of these areas. If you have described an experience elsewhere in the application, it is
not necessary to repeat the information here.
BUSINESS AGRICULTURE AND ENVIROIDIENT SKILLED TRADES
Accounting/Bookkeeping Beekeeping Auto/Diesel Mechanics
Business Management Environmental Education/Conservation Construction
Business Training Farming (after age 13) Electricity
Cooperatives/Credit Unions Fisheries Masonry
Fund-raising 4-H/FFAlFHA Metalworking
Marketing Forestry/GreenhouselNursery Plumbing
Volunteering with or ParkslWildlife Vocational Education
working for non-profits Vegetable Gardening Woodworking
EDUCATION/TEA(~HING HEALTH AND SOClAL SERVI(.'ES OTHER

Adult Education Health Outreach Computer Science
Business Education Home Economics Computer Literacy
EnglishiESLITEFL Tutoring Social Work/Counseling
Art/Drama Youth Work/Coaching/Sports
Library Experience
Specific activity: From (mo/yr) to (mo/yr) Hours per week
24. CROSS-CULTURAL EXPERIENCE

Peace Corps Volunteers must be open to ideas and cultures different from their own. Give an example of a
significant experience that illustrates your ability to adapt cross-culturally. You may draw from experiences
in your work, school, or community in the U.S. or abroad. Please include the circumstances of the
experience and dates.
10
_......--------------------------------------------------------------------------
,
25. l\IOTIVATION STATEl\IENT

Peace Corps service presents major physical, emotional, and intellectual challenges. You have provided information
on how you qualify for Peace Corps service elsewhere in the application. In the space below, please provide a
statement (between 150-500 words) that includes:
• Your reasons for wanting to serve as a Peace Corps Volunteer; and

Sign and Date the ..

Application on Page 12. "
11
REQUEST :FOR RACIAL AND ETHNIC DATA
This infonnation is voluntary. Your response will not affect consideration of your application. By prOViding this information
you will assist us in assuring that the Peace Corps is administered in a nondiscriminatory manner and reflects the diversity
of the United States.
The infonnation requested in this section is covered by the Privacy Act Notice on the following page.
Please check the box next to the classincation that applies to you.
o Black, not of Hispanic origin (1)
o Hispanic (a person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture
or origin, regardless of race) (2)
o American Indian or Alaskan Native (a person haVing origins in any of the original peoples of North America) (3)
o Asian or Pacinc Islander (a person haVing origins in any of the original peoples of the Far East, Southeast Asia,
the Indian subcontinent, or the Pacillc Islands. This area includes, for example, China, India, Japan, Korea, the Philippines,
Samoa, and Vietnam.) (4)
o White, not of Hispanic origin (haVing origins in any of the original peoples of Europe, North Africa, or the Middle East) (7)
o More than one of the above. (Comment if you Wish) (5)
1)
Privacy Act and Papenyork Reduction Notice
The Peace Corps, an agency of the Federal Government, is required by provisions of the Privacy Act
of 1974 (5 u.s.c 552a) to advise you of the following information regarding this application:
A. This application is authorized by provisions of the Peace Corps Act (22 U.s.C 2501, et seq.),
which authQrize the collection of information regarding the suitability and qualifications
of applicants.
B. The principal purpose for which the information provided will be used is to evaluate your
suitability and qualifications to serve in a Peace Corps full-time volunteer program.
C Information in this application may routinely be disclosed as follows:
1. to host country agencies for the purpose of determining placement, obtaining visas,
and other program-related matters;
2. to police or judicial authorities where appropriate;

3. to the Treasury and other Federal agencies for use in connection with support payments
and Social Security and Federal Income tax matters;
4. to the Office of Personnel Management, other Federal agencies, and others, if necessary,
for the purpose of a background suitability investigation;
5. to other Federal agencies having an interest in employment of the applicant or Volunteer,
provided that except for information required for authorized security clearances,
information provided will be limited to dates of service and a standard description of service;
6. to a court or other appropriate tribunal upon subpoena or other request;
7. to a member of Congress upon request indicating that such member has been requested
by an individual about whom the record is maintained to obtain such information;
8. a source for management information or preparation for statistical reports
(without personal information);
9. to the National Archives and Records Administration, GSA, in authorized
management inspections;
10. when required under provisions of the Freedom ofInformation Act (5 U.S.C 552) and
Privacy Act (5 U.S.C 552a);
11. to the Bureau of the Census for the purposes of planning or carrying out a census surveyor
related activity pursuant to the provisions of Title 13, U.S. Code;
12. to Peace Corps personnel who have a need for the information in the performance
of their duties;
13. to the Volunteer's family members in emergency situations; and

14. in the case of United Nations Volunteers, to appropriate UN officials.
D. The completion of this application is voluntary; however, failure to provide information

requested may result in the Peace Corps' inability to assess the qualifications of an applicant
and result in non-selection for the volunteer program for which that applicant has applied.
E. The Peace Corps estimates that it will take 8 hours to complete this form. Send comments on
this form to Peace Corps, Paperwork Reduction Project, Washington, DC 20526. OMB control
number: 0420-0005. The Peace Corps may not conduct or sponsor, and a person is not
reqUired to respond to, a collection of information unless it displays a currently valid OMB
control number. Continuous use form.
Peace (~OIl)S Regiollal Offices
Call toll-free at (800) 424-8580 and press
" 1 " to he connected to the office nearest yon.
www.peacecorps.gov
ATLANTA LOS ANGELES

(GA, AL, Ii'L, 1\IS, PR, se TN) (Southem (:A, .A2)
Peace Corps Regional Office Peace Corps Regional Office
100 Alabama Street, Building #1924, Suite 2R70 11000 Wilshire Boulevard, Suite 8104
Atlanta, GA 30303-8702 Los Angeles, CA 90024-3670
(404) 562-3456 (310) 235-7444
BOSTON 1\UNNEAPOLIS
(1\IA, ME, NH, RI, VT) (l\1N, lA, ND, SD, WI)
10 Causeway Street, Room 450 330 2nd Avenue, South, Suite 420
Boston, MA 02222-1099 Minneapolis, MN 55401-9802
(617) 565-5555 (612) 348-1480
cmCAGO NEW YORK

(IL, IN, KY, 1\U, 1\10, OH) (NY, CT, NJ, PAr VI)
55 West Monroe Street, Suite 450 6 World Trade Center, Room 611
Chicago, lL 60603-5001 New York, NY 10048-0900
(312) 353-4990 (212) 637-6498
DALLAS SAN }'RAN(lSCO

(TX, AR, LA, ml, OK) (Northem CA, HI, NY)

207 S. Houston Street, Room 527 333 Market Street, Suite 600
Dallas, TX 75202-4790 San Francisco, CA 94105-1914
(214) 767-5435 (415) 977-8800
DENVER SEATTLE
~A,~,ID,1\IT,OR)
(CO, KS, NE, UT, WY)
1999 Broadway, Suite 2205 2001 Sixth Avenue, Suite 1776
Denver, CO 80202-3050 Seattle WA 98121-2522
(303) 844-7020 (206) 553-5490
WASHINGTON, D(:
(DC DE, 1\ID, NC, VA, WV)
1400 Wilson Boulevard, Suite 400
Arlington, VA 22209-2405
(703) 235-9191
TOO Services are available. PC-lS02 (rev. 10/98)

Printed on recycled paper
PEA C E.C 0 R P S
of the United States of America
VOLUNTEER APPLICATION
The First Step to Opportunities for You ...

and the World.
INFORMATION FOR THE APPLICANT
To be a Peace Corps Volunteer, you must: In the host country you will:
be a United States citizen 1 work for a government department, an independent agency

be at least 18 years old (there is no upper age limit) or other organization
have technical and personal skills that will qualify you for be supervised by and work with people of the host country
Peace Corps Service speak the language of the people
meet legal, security and medical requirements live as the host country people do and on the living
allowance allotted to you
be subject to local laws
adjust your vacation and holidays to the local situation
INFORMATION FOR MARRIED COUPLES

Married couples are encouraged to apply to Peace Corps and have contributed much to Peace Corps programs over the years.
Because both spouses must serve as volunteers overseas, programmers must ensure that there are compatible job assignments
and work sites which can accommodate couples. This process can be complex and time-consuming.
We therefore ask for your patience and flexibility throughout the process.
INSTRUCTIONS FOR COMPLETING THE APPLICATION

Before you complete your application please read our brochure, Answer each question as completely as possible. If you
"The toughest job you'll ever love" and the instruction sheets need additional space attach a piece of paper. Be sure to
accompanying this application. Fill out your application identify the number of the question you are answering and
carefully. Use it to tell us as much about yourself as you can. make sure that your name and social security number
We recommend that you scan through the documents before appear on it.
beginning.
We are pleased you are about to apply to the United States Peace Corps. The application which follows is challenging,
but well worth the effort. Over 130, 000 current and former volunteers could tell you just how much. If you have
questions as you proceed through the form, don't hesitate to contact the Recruiting Office nearest you. A Peace
Corps representative will be pleased to assist you.
IMPORTANT
Remove the PEACE CORPS APPLICANT REFERENCE LIST between pages 5 and 6 before
completing this application to prevent damaging the carbon copy. Be sure to return the
completed reference list with the completed application.
OUB Control Number 040005

PEACE CORPS VOLUNTEER APPLICATION Eatimated completion lime: 1 hour
. PLEASE TYPE OR PRINT IN BLACK INK
1. NAME
First MI Last
2. SOCIAL SECURITY NUMBER 3. DATE OF BIRTH 4. SEX
ITO IT] ITIIJ Numeric Month

/
Day
/
Year
F_ _ M_ _
5. AVAILABILITY FOR SERVICE Indicate the earliest date you will be available for Peace Corps training.
/ / Please notify us If your availability date changes.
Numeric Month Day Year
6. PREVIOUS APPLICATION FOR PEACE CORPS SERVICE

A. Have,xg.u applied p-l1Ivloualy? B. Have,xg.u participated In Peaca Corps training? C. Have.J!!.u been a Peace Corps volunteer?
YesU NoD. YesU
If yes to any of the above, please give dates and location!.&-.
NoD YesU NoD _
7. CITIZENSHIP EVERYONE MUST ANSWER 7A

A. Are you a citizen of the United States? Yes 0 No 0 Place of birth _
B. Naturalization Number if you are a naturalized citizen - _
8. ADDRESS
A. Current Mailing Address C. Permanent Mailing Address

(All information will be sent to this address until you (Name and address of person through whom you can
notify Peace Corps of a change in address.) always be reached.)
NUMBER AND STREET FIRST NAME LAST NAME
CITY AND STATE ZIP CODE NUMBER AND STREET
(AREA CODE) HOME PHONE CITY AND STATE ZIP CODE
(AREA CODE) BUSINESS OR SCHOOL PHONE (AREA CODE) HOME PHONE
B. Do ~ ex~ect to move in the next 12 months?

YesU NoD
(AREA CODE) BUSINESS OR SCHOOL PHONE
If yes, when I I
Numeric Month Cay Year
N T WRITE IN THI PA E.
Mar~al _ _ Spouse last name· Spouse SSN Dependents _

Lang 1 _ _ Exp Lang 2 _ _ Exp Lang 3 ExpEd level College 1 _
Degree 1 Major 1 Minor 1 Grad dale 1 College 2 Degree 2 _
Major 2 _ _ Grad dale 2 Skill 1 SkiD 2 _ _ SkiD 3 _ _ Skill 4 _ _ Skill 5 _ _ Source _ _ •
EC Recru~er Sialus Legal Dale Completed by
2
PEACE CORPS LEGAL INFORMATION
INTELLIGENCE POLICY
In order to protect the safety of the volunteers and maintain t~e trust and confidence of those in the countries we
serve, it is crucial that there be a total separation of Peace Corps from intelligence activities, both in reality and
appearance. Thus, the Peace Corps excludes from volunteer service persons who have been associated with
intelligence activities.
"Intelligence activity" includes any activity related to clandestine collection of information, or the analysis or
dissemination of such information, intended for use by any government in formulating or implementing political or
military policy in regard to other countries. The term "associated with" includes employment, contractual and/or familial
relationships. .
Current or former employees of the Central Intelligence Agency are permanently ineligible for Peace Corps service.
Employees of an agency or division of an agency whose mission is intelligence gathering, and persons whose
background or work history discloses a substantial connection with an intelligence activity other than through
employment, are ineligible for at least ten years from the date of their last connection with the agency or activity. A
family relationship to an employee of an intelligence agency may also be a disqualifying factor.
Before completing Block 9 applicants who may have had an "association" with the Central Intelligence Agency, or the
Defense Intelligence Agency, should consult (or have the family member consult) with the General Counsel of the
respective agency, who will in tum, consult with Peace Corps General Counsel. Other applicants with questions may
consult directly with the Peace Corps General Counsel.
SECURITY REQUIREMENTS
No applicant can be selected for volunteer service until a background investigation has been performed. The Peace
Corps requires that all applicants accepted for training have, as a minimum, a National Agency Check (NAG)
background investigation. No applicant is permitted to depart for overseas training unless this background
investigation has been initiated. Exceptions to this policy can only be made with the written approval of Peace
Corps' Office of General Counsel. In no case, however, maya trainee be sworn in as a volunteer prior to the
c;ompletion of his or her background investigation. Forms and fingerprint charts necessary for this investigation will be
sent to you at a later point in the application process.
9. INTELLIGENCE ACTIVITIES AND ORGANIZATIONS

Before answering, please read 'Peace Corps Legal Information' on this page.
A. Are you now or have you ever been associated with intelligence activities of any agency of the U.S. Government or any other
government? YES 0 NO 0
B. If yes, provide details inclUding dates and agency or division for whom the work was performed and/or nature of association.
If military, give your MOS number and any service schools attended on a separate sheet of paper and attach to this page.
10. MILITARY STATUS

A. Are you now a member of the ROTC, National Guard or Reserves? YES 0
If yes, how will you fulfill your obligation?
~., Have you ever served in the Armed Forces? YES 0

Branch SeriaVFile number

Highest rank held Dates of service From To
Type of discharge
,
C. If your discharge was of any type other than honorable, explain the circumstances in detail on a separate sheet of paper and
attach to this page.
3
- PEACE CORPS MEDICAL INFORMATION
Each trainee and volunteer must submit to a thorough medical evaluation. This review is for your protection against
health hazards which you could encounter in a developing,~untry. To begin this evaluation, please complete the
medical history section on the other side of this page. Later in the application process you will undergo thorough
medicaVdental exams, tests and immunizations deemed necessary for your safety.
As part of the medicaVdental clearance process, you will be required to provide a medical certificate that you are
seronegative for the antibody to human immunodeficiency virus (HIV), the causative agent of AIDS (acquired immune
deficiency syndrome). You may fulfill this testing requirement as part of the general pre-entrance medical examination
process, or separately through your own arrangements. In either case, the results can be directly given to you, if you
wish. (All states provide free testing at alternative test sites; addresses are available at your State Health Department.)
Applicants have the right to withdraw their applications at any time without explanation.
Peace Corps will pay for this and other tests required in the amounts indicated on the medical packet you will receive if
you are nominated or invited to an assignment.
11. PERSONAL HEALTH INFORMATION

Individuals with handicaps and other individuals with health or medical problems who can, with reasonable
accommodation, perform volunteer assignments and who are otherwise qualified. are eligible to serve as Peace Corps
Volunteers. To determine whether you are medically qualified for volunteer service and to enable Peace Corps to
identify the overseas assignments which are appropriate to any health problems you may have, the following
Questions must be answered completely and accurately. Failure to do so may delay processing of your application or
result in withdrawal of your nomination or invitation on suitability grounds if such failure to disclose is determined to be
intentional.
Please complete the information below and turn page for medical history.
First MI Last
SOCIAL SECURITY NUMBER
ITIJ IT] ITIIJ Today's date
A. Statistics
Height: _ _ _ _ft. ____in. Weight: ____Ibs. Age: _
Are you a former Peace Corps Volunteer? Yes 0 NoD

If "yes" when? Country: _
IMPORTANT: PLI;ASE COMPLETE THE MEDICAL HISTORY SECTION
ON THE REVERSE SIDE OF THIS PAGE ~
B. Medical History Please describe the nature of the condition,

treatment, results, and dates for everything
checked "yes" under medical history. Add any
Do you suffer from or have you ever been other pertinent medical Information you would like
to Include or think we should know. Use additional
treated for any of the following: sheets and attach to this page, If necessary.
1 asthma yes 0 noD

2 diabetes yes 0 noD
3 heart ailment yes 0 noD
4 liver problems yes 0 noD
5 stomach or intestinal problems yes 0 noD
6 cancer yes 0 noO
7 high blood pressure yes 0 noO
8 joint or back problems yes 0 noD
9 kidney problems yes 0 noD
10 epilepsy/neurological problems yes 0 noO
11 eye problems yes 0 noO
12 lung problems yes 0 noD
13 thyroid problems yes 0 noO
14 skin diseases yes 0 noO
15 hernia yes 0 noD
16 pilonidal cyst yes 0 noO
17 alcoholism yes 0 noO
18 drug abuse yes 0 noD
19 Do you need any special medical or dental services? yes 0 noD
20 Have you ever had any psychological counseling or therapy? yes 0 noO
21 Are you allergic to any medicines (e.g. penicillan, sulpha, etc.), insect stings, foods, animals, oroants?
yes noO
22 Have you had surgery other than a tonsillectomy, hernia repair, abortion, appendectomy, or wisdom teeth
removal? yes 0 no 0
23 Are you now under the care of a doctor or other practitioner for any reason? yes 0 noD
Before SUbmitting this application to Peace Corps, please detach and place this page (and any
additional pages) In the ltnclosed envelope. Seal the envelope and staple It to the application.
The Information will be seen only by a limited number of authorized person nel. Please print or
tYDe your name and social security number on the front of the enveloDe.
12. MARITAL STArus - Everyone must check an appropriate box. Check all boxes that apply to you.
1 0 Single (never married) 5 0 Widowed (list below)
2 0 Plan to marry within one year (date of expected marriage -1) 6 0 Divorced or legally separated
3 0 Married - Living with spouse (date of marriage ) (list below)
0
~I
4 Married - Not living with spouse (list below)
List the names of former spouse(s) as well as the year(s) of divorce, separation, or death:
NAME OF FORMER SPOUSE(S) YEAR NAME OF FORMER SPOUSE(S) YEAR
If engaged or married, do you plan to serve with your fiance/spouse? YES 0 NO 0
If yes, please attach applications before submitting them to Peace Corps.
If you are applying for Peace Corps service and your spouse plans to accompany you, he/she must apply to serve as a volunteer before you can
be considered for placement.
Indicate name and social security number of fiance/spouse: SOCIAL SECURITY NUMBER
I I I I I I
First Nama MI Last Nama
13. CHILDREN AND OTHER DEPENDENTS - Everyone must answer A.

A. Are any persons partially or totally dependent upon you for their support whether or not they are living with you? YES 0
B. Ust all children under age 18 whether or not they are dependent upon you for financial support.
NAME OF CHILD ADDRESS AGE DEPENDENT? (YESINO)
C. List all dependents not listed above.
NAME OF DEPENDErliT ADDRESS RELATIONSHIP
D. Do you have adequate means to continue support obligations while serving as a volunteer? YES 0NO 0
If yes, please specify what arrangements would be made to meet your support obligations on a sheet of paper and attach to this page.
14. LEGAL INFORMATION - EVERYONE MUST ANSWER 14 A, Band C.

A. Have you ever been convided of any offense, (including felonies and misdemeanors) by a civilian or military court or have you been subjected
to any disciplinary action by a military court or a tribunal? (Do not include traffic violations for which the sentence consisted only of a fine of
$200 or less, or any offense that occurred before your eighteenth birthday.) YES 0 NO D
B. Are you now under charges for any offense (inclUding charges for traffic offenses), or are any civil suits or judgements now.e;nding against
~ ~u NOD
If you answered yes to either of the above, provide details on a separate sheet of paper. State your name, date and place of each arrest, suit,
or judgement. Give the nature of the charge or suit, and current status or disposition including any sentence or fine imposed. Provide a
complete explanation of the circumstances and attach it to this page. This information will be treated confidentially.
C. Do you have any outstanding financial obligations, including student loans, that cannot be satisfied prior to training?YES D NO 0
Identify student loans below: (We suggest that you contact your lending institution before filling out the chart below.)
lYPE OF STUDENT LOAN AMOUNT OF LOAN PRINCIPAL DEFERRABLE (YeslNo) INTEREST DEFERRABLE (YeslNo)
Please specify the nature of all other financial obligations which cannot be satisfied prior to entering Peace Corps training on a
separate sheet of paper and attach to this page.
,
FAILURE TO PROVIDE ALL REQUESTED INFORMATION MAY LEAD TO IMMEDIATE DISQUALIFICATION FOR APPLICANTS
AND IMMEDIATE SEPARATION FOR TRAINEESNOLUNTEERS.
6
15. PRACTICAL EXPERIENCE FOR PEACE CORPS SERVICE
Peace Corps programs are divided into 5 general work categories. While a majority of the jobs require a specific degree, there are
some where experience alone may qualify you for an assignment in the Peace Corps. Here we would like to know whether you have
any experience in these general areas. We will be asking for more detailed information later on in the process. Remember, there is a
wide range of experiences that may qualify you for a program. In addition to actual job experience, we also value summer and part
time work, volunteer work, and activities such as home gardening, beekeeping, community involvement, etc. Please read the list
below and check those areas where you have at least minimal experience within the past ten years. Please note that this Is
not the only section we will be reviewing as we assess your qualifications for Peace Corps Service.
Level of Experience Dates of Involvement

CATEGORY From To Brief Description of
Minimal Some Extensive Mo/Yr Mo/Yr Experience
1 . FOOD PRODUCTION &
NATURAL RESOURCES
a) Vegetable gardening
b) 4-HlFFA
c) Farm experience (After age 13)
d) Ag. Economics
e) Environmental Education
f) ParkslWildlife
g) Soil SciencelPlant Pathology
h) Animal Husbandry
i) Forestry/Greenhouse/Nursery
j) Fisheries
k) Beekeeping
2. BUSINESS &
ENGINEERING
a) Business Management
b) Cooperatives/Credit Unions
c) Accounting
d) Bookkeeping
e) Secretarial Work
f) Computer Science
g) Mechanical Engineering
h) Sanitary/Environmental Eng.
i) Civil/Structural Eng.
3. SKILLED TRADES
a) Plumbing
b) Woodworking
c) Construction
d) Mechanics
e) Masonry
f) Metalworking
g) Vocational Ed.
h) Industrial, Arts
- (SECTION 15, PRACTICAL EXPERIENCE FOR PEACE CORPS SERVICE ...CONTINUED)
CATEGORY Level of Experience Dates of Involvement

From To Brief Description of
Minimal Some Extensive ,~
Mo/Yr Mo/Yr Activities
4. HEALTH AND SOCIAL
SERVICES
a) Nutrition
b) Home Economics
c) Social Work
d) Community Development
e) Youth Work/Coaching
5. EDUCATION/TEACHING
a) Primary Education
b) Secondary Education
c) Special Education
d) Business Education
e) Adult Education
f) Teacher Training
g) Engiish/ESLITEFL teaching
h) Engiish/ESLITEFL tutoring
16. LICENSES/CERTIFICATES
List job-related licenses or certificates that you have, such as: nursing; teaching; lifesaving; CPR, etc.
DATE OF LICENSE OR STATE OR OTHER LICENSING
LICENSE OR CERTIFICATE CERTIFICATE AGENCY
1)
2)
3)
17. HOBBIES, HANDICRAFTS, OTHER SKILLS AND ACTIVITIES

Describe below any additional hobbies, activities, or other interests not elsewhere included. Check one box to
indicate the extent of your involvement.
Level of Competence
DESCRIPTION OF SKILL OR INTEREST Slight Skilled Can earn a
KnowledQe Amateur livinQ
(1 )
(2)
(3)
18. LANGUAGES List languages known or studied within the past ten years below.
For each category below, give us the number of years of
experience in the language (Le., studied or spoken): Speaking Ability
Language H.S. Coil. Home Travel (Specify Country) Poor Fair Good Exc.
Spanish ~
French
Other:
Other:
19. EDUCATIONAL BACKGROUND

Check the box for the highest level of education you will have completed by your availability date:
10 Did not complete High Schoof 40 AA degree or equivalent 70 Graduate Study <0 Other (specify GEDetc.:
20 High School Graduate 50 3rd year 01 college completed aO Graduate Degree
30 One or two years 01 college completed 60 College Graduate 90 Technical School Graduate
Beginning with the most recent, list all schools attended since and including high school:
Dates attended
From To Type of degree Date recv'd
Name of School/City & State Major/Minor mo/yr mo/yr or certificate or expected
20. COURSEWORK
In addition to your major and minor, we would like to know your coursework in the specific areas listed below.
Complete this item if you will have two or more years of college, trade school or equivalent specialized training by your
availability date. Enter the number of credits received for each area you have studied as an undergraduate and a
graduate student. List semester credits under the "Sem" column and quarter credits under the "Otr" column. Please
incue
I d a COpy 0 f your transcript if available.
SUBJECT Undergrad cr. Grader. SUBJECT Undergrad cr. Grad cr.
Sem Qtr Sem Otr Sem Qtr Sam Otr
Agronomy Natural Resources
Ag. Economics Ornamental Hort.
Ag. Engineering Parks/Recreation
Ag. Mechanics Park Planning!Admin.
Biology Physics
Botany Plant Pathology
Chemistry Resource Mgt.
Conservation/Ecology Watershed Mgt.
Entomology Other Agriculture
Environmental Ed. 1
Env. Science/Studies 2
Forestry 3
Geology Other Science
Landscape Arch. ; 1
Mathematics 2
f.
21. EMPLOYMENT RECORD

In this section, please include any self-employment, home management, full or part-time, salaried or volunteer employment. Start
with your cummt or most recent experience, and go back ten years or until date of high school
graduation. Use additional sheets if necessary. Even If you submit a resume, this section must be completed.
(A) Company/Organization Title:
Name: Duties & Responsibilities: _
City &State: _
From: To:
--"'""""';(-m-Oly~r)--- ----:-(m-o--:Iy-r.,....)--
Hrs. per week: _
Reason for leaving:
(8) Company/Organization Title:
City &State: _
From:
--"'""""';(-m-oly~r)---TO:----:-(m-o--:Iy-r.,....) --
Hrs. per week: _
Reason for leaving:
(C) Company/Organization Title:
City &State: _
From:
--"'""""';(-m-oly~r)---TO:----:-(m-o.....,ly-r.,....) -
Hrs.·perweek: _
Reason for leaving:
(0) Company/Organization Title:
City &State: _
From: To:
--"'""""';(~m~oly=r)--- ----:-(m-o.....,ly-r':"'")--
Hrs. per week: _
Reason for leaving:
(E) Company/Organization Title:
City &State: _
From: --"'""""';(-m-oly~r)---TO:----:-(m-o--:Iy-r.,....) - -
Hrs. per week: """- _
Reason for leaving:
22. TIME GAPS
Please explain periods of time. greater than 2 months, not otherwise accounted for by employment, school, military,
etc. Give specific dates for each activity:
10
23. COMMUNITY/VOLUNTEER ACTIVITIES

Peace Corps Volunteer assignments require applicants who demonstrate leadership, creativity, initiative and an ability
to work with others. Please describe any active community, volunteer or organizational work in which you have
participated. We are specifically interested in activities which demonstrate the following skills or abilities:
* Initiative in starting or carrying out activities; .~
Planning activities involving others;
* Organizing other people to participate in activities or to perform tasks;

* Motivating others to involve themselves and to maintain their involvement;
* Active leadership, supervision or management of others.
List your most recent activity first. Use additional sheets of paper, if necessary.
(A) Name of Organization
Position(s) held:
Involvement: From: To: # hrslrnonth'-- _
(mo/yr) (rno/yr)
(B) Name of Organization
Position(s) held:
Involvement: From:~_~__To: #, hrslrnonth'-- _
(molyr) (mo/yr)
(C) Name of Organization
Position(s) held:
Involvement: From: To: # hrslrnonth, _
(mo/yr) (mo/yr)
24. CROSS-CULTURAL EXPERIENCE

Peace Corps volunteers must be able to observe, accept and cope with the ideas, behaviors, and customs of people
different from themselves. If you can, please give an example of a significant experience you have had with people
different from yourself. This could be through foreign travel or at home in your work, school, church and community
groups.
1 1
25. MOTIVATION STATEMENT

While most Peace Corps Volunteers over the years have been positive about their overseas experiences, service in a
developing country presents major physical, emotional, and intellectual challenges. Below, please provide a
statement that includes:
1 - your reasons for wanting to serve overseas as a Peace Corps Volunteer, and
2 - how you see your reasons for wanting to serve as a volunteer are related to your personal life goals and past
activities.
26. VOLUNTEER WORK ASSIGNMENT PREFERENCE

In order of preference, please list and describe the type of volunteer assignments in which you would prefer to work.
1. _
2. _
3. _
12
. 27. GEOGRAPHIC AREA OF ASSIGNMENT

. Countries make requests for volunteers once or twice a year. Requests are subject to change. sometimes at the last
moment. This makes it difficult to always place applicants in the region of their preference. Also, final placement
depends upon how well your experience and background meet the requirements of a specific assignment. We
therefore ask you to be flexible about your geographic area of Assignment. However, if you do have a preference for a
particular region of the world. we may be able to honor it. Please 'check the appropriate box below to indicate what
kind of preference you have. if any.
D No preference
D Africa D North Africa D Middle East D Eastern Europe
0 Asia D Pacific D Caribbean D Latin America
Please explain your preference:, _
Please indicate any countries in which you would not want to work and why: _
28. CERTIFICATION
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. , understand that any misinformation may be
cause for disqualification or termination.
Signature ·Date
NOTES
'APPLICATION COMPLETION TIME

Peace Corps estimates that the average time to complete this form is 1 hour, including the time to assemble the information. If you have any comments
concerning the accuracy of this estimate and any suggestion for reducing it, please address them to Peace Corps; Paperwork Reduction Project (0420
0005), Room 5316; 1990K Street, NW.; Washington, D.C. 20526 and to the Office of Management and Budget; Paperwork Reduction Project (0420
0005); Washington, D.C. 20503. ;
13
REQUEST FOR RACIAL AND ETHNIC DATA
This information is voluntary and is requested solely for the purpose of determining compliance with federal civil
rights law, and your response will not affect consideration of your application. By providing this information you will
assist us in assuring that the Peace Corps is administered in a nondiscriminatory manner.
The information requested in this section is covered by thErprovisions of the Privacy Act described below.
Please categorize yourself by placing an "x" in the box next to the proper category.
D Black, not of Hispanic origin (a person having origins in any of the Black racial groups of Africa). (1)
D Hispanic (a person of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin,
regardless of race). (2)
D American Indian or Alaskan Native ( a person having origins in any of the original peoples of North America, and
who maintains cultural identification through tribal affiliation or community recognition). (3)
D Asian or Pacific Islander (a person having origins in any of the original peoples of the Far East, Southeast Asia, the
Indian subcontinent, or the Pacific Islands. This area includes, for example, China, India, Japan, Korea, the
Philippines, Samoa, and Vietnam.). (4)
D White, not of Hispanic origin (having origins in any of the original peoples of Europe, North Africa, or the
Middle East). (7)
D More than one of the above. (Comment if you wish) (5)
IMPORTANT
Discrimination based on race, color, national origin, religion, age, sex, handicap, or political
affiliation Is prohibited. All services are administered on a non-discriminatory basis. Anyone
who feels he/she has been discriminated against should contact the Peace Corps, Equal
Employment Opportunities Office Washinaton D.C. 20526
PRIVACY ACT NOTICE

Peace Corps, an agency of the Federal Government, is required, by provisions of the Privacy Act of 1974 (5 U.S.C. 552a), to
advise you of the following information regarding this application:
a) This application is authorized by the provisions of the Peace 6) to a court or other appropriate tribunal upon subpoena or other
Corps Act (22 U.S.C. 2501, et seq.) which authorize the request;
collection of information regarding the suitability and 7) to a member of Congress upon request indicating that
qualifications of applicants. such member has been requested by an i.ndividual about whom
the record is maintained to obtain such information;
b) The principal purpose for which the information provided herein 8) information may be used as a source for management
will be used is to evaluate your suitability and qualifications to information or preparation for statistical reports (without personal
serve in a Peace Corps full-time volunteer program. information);
9) to the National Archives and Records Administration, GSA, in
c) Information in this application may routinely be disclosed as authorized management inspections;
follows: 10) when required under provisions of the Freedom of Information
Act (5 U.S.C. 552) and Privacy Act (5 U.S.C. 552a);
1) to host country agencies for the purpose of determining
11) to the Bureau of the Census for the purposes of planning or
placement, obtaining visas, and other program related matters; carrying out a census surveyor related activity pursuant to the
2) to police or judicial authorities where appropriate and properly
provisions of Title 13; and
requested;
12) to Peace Corps personnel who have a need for the
3) to the Treasury and other Federal agencies for use in
information in the performance of their duties;
connection with support payments and Social Security and
13) to the Volunteer's family members in emergency situations;
Federal Income tax matters;
14) in the case of United Nations Volunteers, to appropriate UN
4) to the Office of Personnel Management, other Federal
officials;
agencies, and others, if necessary, for the purpose of a
background suitability investigation; d)The completion of this application is voluntary; however,
5) to other Federal agencies having an interest in employment of failure to provide information requested may result in Peace
the applicant or volunteer, provided that except for information Corps' inability to assess the qualifications of an applicant
required for authorized security ,clearances, information provided and result in non selection for the volunteer program applied
will be limited to dates of service and a standard description of for.
service;
1 4
When completed, this application and reference should be mailed to the nearest Peace
Corps Recruitment Office. (See list below)
If you have further questions about Peace Corps service or would like additional help
completing this application, contact a representative at the Peace Corps Office nearest you.
Peace Corps Recruitment Offices
BOSTON (MA, VT, NH, RI, ME) ATLANTA (GA, TN, MS, AL, SC, DALLAS (TX, OK, LA, NM, AR)
KY)
Peace Corps Recruiting Office Peace Corps Recruiting Office
10 Causeway St., Room 450 Peace Corps Recruiting Office P.O. BOX 638
Boston, Massachusetts 02222 101 Marietta 5t., NW 400 N. Ervay St., Room 230
617-565-5555 Room 2324 Dallas, Texas 75221
800-648-8052 Atlanta, Georgia 30323 214-767-5435
404-331-2932 800-442-7294 (TX only)
MIAMI (FL) 800-241-3862 800-527-9216 (AR, NM, OK, LA)
Peace Corps Recruiting Office
CHICAGO (IL, IN) DENVER (CO, MT, SO, NO, UT,
330 Biscayne Blvd., Room 420
WY)
Miami, Florida 33132 Peace Corps Recruiting Office
305-536-5273 50 E. Washington St., Suite 300 Peace Corps Recruiting Office
800-468-2745 (FL only) Chicago, IL 60602 1845 Sherman St., Room 103
312-353-4990 Denver, CO 80203
NEW YORK (NY, Northern NJ, CT) 800-621-3670 303-866-1057
800-525-4621 (MT, SO, NO, UT,
DETROIT (MI, OH) Wf)
90 Church St., Room 1317
New York, New York 10007 Peace Corps Recruiting Office
LOS ANGELES (Southern CA. AZ)
212-264-6981 P.V. McNamara Federal Building
477 Michigan Ave., Room M-74

PHILADELPHIA (PA, DE, Detroit, Michigan 48226
11000 Wilshire Blvd., Suite 8104
Southern NJ) 313-226-7928.
West Los Angeles, CA 90024
800-521-8686 (OH only)
213-575-7444
800-533-3231 (MI only)
800-832-0681
U.S. Customs House, Room 102-A
Philadelphia, Pennsylvania 19106
KANSAS CITY (KS, MO, lA, NE) SAN FRANCISCO (Northern CA.
215-597-0744
NV,HI)
800-462-1589 (PA) Peace Corps Recruiting Office
5799 Broadmoor, Suite 512 Peace Corps Recruiting Office
PUERTO RICO (PR, VI) Mission, Kansas 66202 211 Main St., Room 533
913-236-2700 San Francisco, California 94105
800-255-4121 415-744-2677
Mercantil Plaza, Room 710
Stop 271/2 Ponce de Leon Ave.
MINNEAPOLIS (MN, WI) SEATTLE (WA. OR, 10, AK)
Hato Rey, Puerto Rico 00918
809-766-6276 Peace Corps Recruiting Office Peace Corps Recruiting Office
330 2nd Ave., South, Suite 420 2001 Sixth Ave., Room 1776
WASHINGTON, D.C. (DC, MD, NC, Minneapolis, Minnesota 55401 Seattle, Washington 98121
WV, VA) 612-348-1480 206-553-5490
800-328-8282 800-426-1022 (Eastern
Washington, OR, 10, AK)
1990 K St., NW 5th Floor
Washington, DC 20526
202-606-3940
800-424-8580, ext. 2226
RMB-30(4J91 )
PC-1502

Peace Corps Online Application 2008 Copy 2

Încărcat de

Informații document

Titlu original

Drepturi de autor

Partajați acest document

Partajați sau inserați document

Opțiuni de partajare

Vi se pare util acest document?

Este necorespunzător acest conținut?

Drepturi de autor:

Peace Corps Online Application 2008 Copy 2

Încărcat de

Drepturi de autor:

Peace Corps Online Application

Information You Will Need

last ten years.

PC-1502 (Revised 6/05) (All previous editions are obsolete)

• Information about your student loans and other financial obligations.

Supplemental Materials To Mail Separately

Peace Corps Application Part II: Health Status Review

Submitting Your Application

If You Are Applying As a Couple

If You Have Questions

We look forward to receiving your application.

PC - 1502 (Revised 6/02) 3 (All Previous editions are obsolete)

Peace Corps Volunteer Application

Type or print legibly in black ink

First Middle (not initial) Last

3. Have you previously: If yes, please provide dates and location

4. Are you applying to the Master's International Program? Yes No

5. Peace Corps Volunteers must be U.S. Citizens or Nationals.

City, State, Country

b. If you are/will be a naturalized citizen, prOVide certificate of naturalization

PC - 1502 (Revised 6/02) 4 (All Previous editions are obsolete)

A. Current Mailing Address

notice of a change of address.

Number and Street Apt. No.

Number and Street Apt. No.

C. Do you expect to move in the next 12 months? Yes No

Month Day Year

7. Social Security Number

Privacy Act Statement

PC - 1502 (Revised 6/02) 5 (All Previous editions are obsolete)·

10. Racial and Ethnic Data

Hispanic (a person of Mexican, Puerto Rican, Cuban, Central or South

American Indian or Alaskan Native - A person having origins in any of

PC - 1502 (Revised 6/02) 6 (All Previous editions are obsolete)

addition, any intentionally false statement may be subject to fines and/or

A. Drug and Alcohol Information

A Volunteer or Trainee (V/T) found to be involved with drugs in a manner not

Applicants charged with or convicted of Public Intoxication, DUI, OWl, or who

PC-1502 (Revised 6/05) 7 (All previous editions are obsolete)

Legal Status and History

Note: It is the responsibility of the applicant to inform the Peace Corps

5. Are you currently a party in a civil suit? Yes/No

12. Financial Obligations:

If yes, please provide the following information (attach a separate sheet if

Type of Financial Obligation -----'Amount _

Note: If someone is assuming payment of your financial obligation(s) during your

PC - 1502 (Revised 6/02) 9 (All Previous editions are obsolete)

13. Intelligence Activities and Organizations

It has been the Peace Corps' longstanding policy to exclude from

Trle policy is founded on the premise that it is crucial to the Peace

"Intelligence Activity" includes any activities or specialized training

Persons currently or formerly employed by the Central Intelligence

In addition to employment with an intelligence agency or division thereof, applicants

Depending upon the nature of an applicant's involvement in or relationship to

PC - 1502 (Revised 6/02) 10 (All Previous editions are obsolete)

In some cases, employment or association with certain intelligence activities or

Based upon the preceding, please answer the following questions:

If yes, how will you fulfill your

If yes, complete the following:

Highest rank held Dates of service:

C. If your discharge was other than honorable, explain the circumstances in

1. Single (never married)

Expected date of marriage: _

PC - 1502 (Revised 6/02) 11 (All Previous editions are obsolete)

3. Married-planning to serve with spouse

4. Married - planning to serve without spouse