Fillable Member Application (The Chickasaw Nation)

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Member Application (The Chickasaw Nation)

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Page 1 of 3 Form no. 04483 CS-PDR Rev. 1/2020
Department of Community Services
Project Development and Review Division / AmeriCorps Program
231 Seabrook Road / Ada, OK 74820 / (580) 559-0963 / Fax: (580) 272-2518
Member Application
Name:
First Middle Last Suffix
Alias/maiden name(s):
Home phone: (___) ___________ Work phone: (___) _____________ Cell phone: (___)
Email: ______________________________________________________________________________
Mailing address:
Street City State ZIP
□ Same as mailing
Physical address:
Street City State ZIP
Social Security no.: Birth date:
Month/Day/Year
Race: □ White □African American □Hispanic □ Other:
□Native American CDIB: □Yes □No Tribal affiliation:
Gender: □ Male □ Female Are you a veteran? □ Yes □ No Shirt size: □ Women’s □ Men’s
Are you interested in: □ Full-time □ Half-time Earliest date you are available to begin service: _________
Month/Day/Year
Have you ever worked with children? □ Yes □ No
Have you ever worked in the emergency management field? □ Yes □ No
Education - Check all levels of education that you will have completed by the time you are planning to serve in
AmeriCorps.
□Some high school □Associate’s degree □Graduate degree
□High school diploma or HSED □Some college □Other (please specify):
□Technical school/Apprenticeship □Bachelor’s degree _________________
Are you currently enrolled in school? □Yes □ No If so, where? ______________________________
List all schools you have attended, including high school, trade or technical schools, military training and
employment training programs.
Name of school
(List most recent first)
Location of
school
(City/State)
Dates attended
Major
or area
of study
Type of
degree or
certificate
Date
received or
expected
To
Mo./Yr.
A.
B.
C.
D.
Bill Anoatubby
Governor
Page 2 of 3 Form no. 04483 CS-PDR Rev. 1/2020
Employment - Beginning with your current or most recent position, list and briefly describe the last three
positions you have held or your last five years of employment. Please include self-employment,
internships/fellowships, home management and full- or part-time paid or unpaid work experience. (You may
attach a resume instead if it addresses the information requested below.)
Name and address of employer
Dates
Job title and duties
A. Organization, City/State
____________________________________
____________________________________
Supervisor: phone and email
____________________________________
____________________________________
____________________________________
From: ____/______
Mo/Yr.
To: ____/______
Mo/Yr.
Hrs./week: _______
Title: ___________________________
Duties: _________________________
Reason for leaving: _______________
_______________________________
_______________________________
Name and address of employer
Dates
Job title and duties
A. Organization, City/State
____________________________________
____________________________________
Supervisor: phone and email
____________________________________
____________________________________
____________________________________
From: ____/______
Mo/Yr.
To: ____/______
Mo/Yr.
Hrs./week: _______
Title: ___________________________
Duties: _________________________
Reason for leaving: _______________
_______________________________
_______________________________
Name and address of employer
Dates
Job title and duties
A. Organization, City/State
____________________________________
____________________________________
Supervisor: phone and email
____________________________________
____________________________________
____________________________________
From: ____/______
Mo/Yr.
To: ____/______
Mo/Yr.
Hrs./week: _______
Title: ___________________________
Duties: _________________________
Reason for leaving: _______________
_______________________________
_______________________________
Community Service - (Previous service is not a requirement.) Describe if and when you have ever reached out
to help others and/or how you have been involved in your own community or school. Explain why you decided to
serve or get involved and what you received in return OR what you learned and how it made you feel. (Your
involvement could include serving in neighborhood, school, religious, social, professional or other volunteer
groups; helping out with community service projects; or participating in less formal activities.)
Why Apply for the Chickasaw Nation AmeriCorps Program? We would like to understand more about you
and your reasons for applying to AmeriCorps. How does AmeriCorps fit into your life right now? What are some of
your experiences that make you the person you are today? Who told you about AmeriCorps or encouraged you to
apply?
Page 3 of 3 Form no. 04483 CS-PDR Rev. 1/2020
References - Please attach two to three references of people who know you well and who are familiar with your
personal background, education, employment and/or professional skills. Consider asking work supervisors,
clergy, teachers, counselors, coaches or someone else familiar with your motivation and community involvement.
Forms are available to assist you with this and this is not a requirement for the application, just an option.
U.S. Citizen - AmeriCorps members must be a United States citizen, U.S. national or lawful permanent resident.
Are you a: □ United States citizen □ U.S. National □ Lawful permanent resident alien
If you are a lawful permanent resident alien and you received your card after January 1987, what is your
registration number and card expiration date? ___________________________________________________
National Service Criminal History Check
Have you ever been convicted of or received a deferred judgment for a crime? □ Yes □ No
If yes, please explain including dates and locations:
□Please initial to consent for the CN AmeriCorps Program to run a National Sex Offender Public Website (NSOPW) search.
(REQUIRED TO SERVE AS AN AMERICORPS MEMBER)
Emergency contact/permanent address: (Please provide the name and address of a person through whom you can always be reached)
Name: Relation:
Mailing address:
Street City State ZIP
Home phone: ( ) Work phone: ( ) Cell phone: ( )
Email:
I certify that the information contained in this application is true and correct to the best of my knowledge.
Applicant signature Date AmeriCorps staff signature Date
Parent/legal guardian signature Date
(if applicant is under 18 years of age)
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Member Application (The Chickasaw Nation)

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Completed 31 January 2021

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