You are on page 1of 4

Corpsmember Application

Date: 12 Sep 2010

Please print or type clearly.


(Last) (First) (Middle)

Date of Birth: 11 / 12 / 1986 Age 23 Male X Female

Are you a United States citizen, national, or lawful permanent resident alien? yes x no

Do you have a high school diploma or GED certificate? x yes no

Current Address:

572 Regimiento 24 Street

Number and Street
Santa Cruz de la Sierra Santa Cruz
City State Zip

Phone (where we can reach you): ( 591 )70076739 Alt. Phone: ( )


Permanent Address: (if different than above)

Number and Street

City State Zip

How did you hear about this program? (please be specific: friend, Web site, teacher, flier)

Please answer on a separate piece of paper:

1. What have been your most meaningful involvements in environmental and/or community
service projects in the past?
How are the environment and community related for you?
2. What is an accomplishment you are proud of? What skills, people and/or experiences enabled
3. you to succeed in the process?
What experience do you have working with groups of people and/or serving in leadership
4. What are your main activities and interests? (i.e. studies, employment, community, hobbies,
volunteer activities, etc.)
5. Why do you want to be a part of this program in the Puget Sound region of the Pacific
Northwest? What two personal goals do you hope to gain from this 10.5-month experience?
How does physical work in the field doing ecological restoration advance your life/career goals?
6. Teamwork is an essential part of work at EarthCorps. What has your experience been working
in teams, and give an example of how you resolve conflicts in stressful or uncomfortable group
Describe a situation when you were a stranger in a community. What were your coping
mechanisms? How did you get work done, get to know people, and get support?
What are the top three environmental and social concerns for you in your community (where
you grew up, where you live now, etc.) and why are they important issues to you?
Why are people poor?
9. Do you have any medical, physical, or psychological conditions that may affect your
participation in the Corps? If yes, please explain. Please describe any medication you are
currently taking or any allergies you may have which may affect your participation in the Corps.


EarthCorps seeks to create a Corps that represents the diversity of King County, WA.
The following question is optional; the information collected will help us to meet this goal.

Which ethnic group do you consider yourself a part of? (Examples: Asian, African, Chicano/a, Native,
Latino/a, Pacific Islander, White).

EarthCorps and AmeriCorps are in search of participants from different economic backgrounds.
This section will establish the size and total income of your household. This information does
not affect your application status.

Including your self, how many people live in your household? 5

Does your total household receive public assistance (such as TANF or Food Stamps)? yes no
If yes, please specify: no
Do you have children who rely on you as their primary caretaker or for financial support?
Yesno no

Please answer the following questions. Existence of criminal conviction/adjudication may or
may not, depending on the circumstances, disqualify you from consideration. However, any
intentional misrepresentation or omission will disqualify you. Do not include minor traffic

Have you ever been:

Convicted of any criminal offense by a civilian court or by military authorities?

Adjudicated or held responsible as a juvenile offender of any criminal offense by a civilian court
or by authorities?

Are you now:

Under charges for any offenses or any civil suits or judgments pending against you?

On probation or parole?

If no, skip the certification below.

If you answered yes to any of the questions above, please provide the following information:

Date: / / Place (City, State):

Charge: Action taken:

Court, Probation, or Parole Officer (Name):

Phone: _____________________


Number and Street City State Zip Code

I hereby certify that the information provided on this application is true, complete, and
correct, to the best of my knowledge and belief.
12 Sep. 2010

Signature Date

Required Legal Information


Please complete the following information for the two references who will complete your reference
forms. Reference forms may be sent directly to EarthCorps, but please be sure they are received by
the application deadline! (Please list references other than family members: i.e. a teacher, employer,
youth group leader, clergy, etc.)

1. Name: Daniel Delgado Phone: 591 72112537

Address or Email Address:

Relationship to applicant: friend and youth leather

2. Name: Ivan Pinto Phone: 591 76059969

Address or Email Address:

Relationship to applicant: working together.

Please return your application, resume, and 2 reference forms to:

EarthCorps - Local Recruitment

6310 NE 74th St., Suite 201E
Seattle, WA 98115
Tel: (206) 322-9296 ext. 102

Fax: (206) 322-9312


For EarthCorps Use Only:

Date Received:/
Reference 1
Reference 2