STEP AmeriCorps Application

We consider applicants for positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of a non-job related medical condition or handicap, or any other legally protected status.
Date of application:*

MonthDayYear
Date
Name*

First NameMiddle InitialLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone*
Please enter a valid phone number.
Type
Additional Phone Number
Please enter a valid phone number.
Type
Email
example@example.com
What is the best way to get in contact with you?*

Phone callText messageEmail
Are you legally eligible for employment in the United States? Proof of citizenship or immigration status will be required for enrollment.*

YesNo
Do you have a means to regularly travel to service sites?*

YesNo
Do you have a valid driver's license?*

YesNo

All positions require a Criminal History, Child Abuse, NSOPW (National Sex Offender Public Website), and FBI clearance prior to placement. Do you consent to a national service criminal history check concisting of the following:
PA State Police Criminal Record Check or Clearance from state of residence?*

YesNo
PA Child Abuse Clearance*

YesNo
FBI Fingerprint Clearance*

YesNo

Employment History

List below all present and past employment, starting with your most recent. If you need more space, please utilize the additional field provided.

References

Please give the name and phone number of three references; two of which must be professional references, one of which can be a personal reference who is not related to you.
I certify that I have not knowingly withheld any facts or circumstances that would detrimentally affect this application. It is agreed that any misrepresentation by me in this application will be sufficient cause for cancellation of an employmemt offer or for dismissal from service if I am employed.

I hereby authorize STEP AmeriCorps to contact my former employers or volunteer agencies unless otherwise indicated, to make inquiries regarding my work record, and/or to contact listed schools for the release of records and transcripts.
Signature*
Date*

MonthDayYear
Date

We consider applicants for positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of a non-job related medical condition or handicap, or any other legally protected status.