LEADS AMERICORPS. Apply today. LEADS AmeriCorps Tulsa Housing Authority 415 East Independence Street Tulsa, OK Phone: (918)

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1 LEADS AMERICORPS Apply today. LEADS AmeriCorps Tulsa Housing Authority 415 East Independence Street Tulsa, OK Phone: (918)

2 We re glad you re interested in becoming an AmeriCorps member. Use this application to apply to the LEADS: Literacy, Education, Activities, Diversity, and Service program of the Tulsa Housing Authority. To learn more about LEADS, please call (918) to receive more information or get answers to any additional questions you may have. PLEASE READ THIS INFORMATION BEFORE COMPLETING THE APPLICATION. Use this application to apply for the LEADS AmeriCorps program. The LEADS program requires this form. If you have received an application form from the Corporation for National Service please keep in mind we require additional information. Using that application may delay your application and/or acceptance into LEADS. Make a copy of this application before you send it in. Send in the original copy of this application. Make certain you sign and date the application. We will not accept faxed applications. You may use additional sheets of paper to provide more detailed information that will not fit on this application form. Enclose everything in the final application packet that you submit. Two references are required for each candidate. They are an important part of your application, and your application cannot be considered without them. Please select two references who have known you for at least one year. Select people who you know well and who are familiar with your personal background, education, employment, and/or professional skills. You should not ask a family member, peer, classmate, co-worker or friend to serve as a reference. The most credible references are teachers, advisors, school counselors, work supervisors, clergy, coaches, or someone else familiar with your community involvement and extracurricular activities. Type or print your application neatly in blue or black ink. Applications may be sent to you via upon request as an attachment. Your application is an important part of the LEADS selection process. After applications are read each application receives a numerical rating there is a total of 72 points possible. We use the following selection criteria: Completion of application (all requested information provided, instructions followed, neatness, grammar and spelling) - 2 points; Education - 5 points; Community or Extra-Curricular Activities (breadth of interest and level of responsibility in organizations, campaigns, projects, etc.) - 20 points; Employment/Volunteer History (Full time or part time, level of responsibility, teamwork, breadth and variety of volunteer activities) - 10 points; Essay- Motivation for joining AmeriCorps (personal insight provided, quality of thought and expression) - 20 points; skills and experiences (quality of expression, analytical ability, ability to work with diverse populations, leadership potential) - 15 points. Spelling and grammar are taken into consideration! Send or bring your ORIGINAL application to Tulsa Housing Authority, Attention: AmeriCorps Program Coordinator, 415 East Independence Street, Tulsa, Oklahoma Faxed applications will not be considered.

3 PERSONAL PROFILE 1. NAME: LAST FIRST MIDDLE 2. Are you a United States citizen, national, or lawful permanent resident alien? Yes No If you are a lawful permanent resident alien and you received your card after January 1987, what is the registration number and card expiration date? 3. SOCIAL SECURITY NUMBER: 4. DATE OF BIRTH: 5. PLACE OF BIRTH: MONTH/DAY/YEAR CITY/STATE/COUNTRY 6. GENDER: Male Female LEADS AmeriCorps. Family Education Mentors provide educational enrichment, healthy futures instruction, and service learning opportunities in the Resource Centers to adults and youth residing in THA properties. Members will focus upon adult self-sufficiency skills and youth literacy programs. All Family Education Mentors must have transportation to travel between THA properties. If you have a preference as to service site, please list it here: (Sites include: Apache Manor, Comanche Park, East Central Village, Mohawk Manor, Parkview Terrace, Riverview Park, Sandy Park, Seminole Hills/Whitlow, South Haven Manor, Towne Square, and Country Club Gardens) Note: We cannot guarantee placement at the service site of your choice. Under no circumstances will an AmeriCorps member be placed in the THA community in which they reside. 7. CURRENT ADDRESS: All information will be sent to this address unless you notify us of a change. NUMBER AND STREET. IF POSSIBLE, INCLUDE A NUMBER AND STREET ADDRESS WHEN USING A P.O. BOX CITY STATE ZIP CODE Home Phone ( ) Work Phone ( ) (IF AVAILABLE) 8. Are you moving within the next six months? Yes No If yes, when? DAY/MONTH/YEAR Please notify us of a new address and phone number at time of move. 10. PERMANENT ADDRESS (If different than above) Please give the name and address of a person through whom you can always be reached: Name: Relationship: NUMBER AND STREET. IF POSSIBLE, INCLUDE A NUMBER AND STREET ADDRESS WHEN USING A P.O. BOX CITY STATE ZIP CODE Home Phone ( ) Work Phone ( ) (IF AVAILABLE)

4 EDUCATION 11. Check the highest level of education that you will have completed by May 31, (Check only one.) Some high school Some college Graduate degree High school diploma or GED Associate s degree Other (please specify): Technical School/Apprenticeship Bachelor s degree 12. List all schools after middle school that you have attended, including high school, trade, technical or business schools, military training and employment training programs (Job Corps, PITC, etc.) Use a separate sheet of paper if necessary. Name of School (List most recent first) A. Location of School (CITY/STATE) Dates Attended From (MO. /YR.) Dates Attended To (MO. /YR.) Major Area of Study Type of Degree or Certificate Date Received or Expected B. C. D. COMMUNITY SERVICE In this section, please list any service related projects in which you have been involved. In detail, describe why became involved, and what benefits you received in return (learning experience, personal growth, satisfaction of helping others, etc). Your involvement could include serving in neighborhood associations, resident associations, school clubs, college organizations, college fraternities/sororities, religious or faith-based organizations, social clubs, professional organizations, volunteer groups, helping out with community service projects (e.g., Operation Clean Sweep, Citizen s Crime Patrol, etc.) or participating in less formal activities such as assisting an elderly neighbor. Note: This section accounts for 28% of your total application score. (Use a separate sheet of paper if necessary.) APPLICATIONS LACKING THIS INFORMATION WILL NOT BE CONSIDERED FOR ACCEPTANCE. EVEN IF YOU DO NOT HAVE ANY COMMUNITY SERVICE INVOLVEMENT, PLEASE MARK NA NOT APPLICABLE WHERE APPROPRIATE. 13. How long have you been involved in your community? If you served in an organization, include the organization name, location, dates and phone number. List your most recent activity first. A. DATES OF INVOLVEMENT: From: To: MONTH/YEAR HOURS PER MONTH: Organization Name: Phone ( ) MONTH/YEAR Location (City/State): Description of Involvement:

5 B. DATES OF INVOLVEMENT: From: To: MONTH/YEAR HOURS PER MONTH: Organization Name: Phone ( ) MONTH/YEAR Location (City/State): Description of Involvement: 14. Have you previously served in AmeriCorps? Yes No Stream of Service (check all that apply): AmeriCorps*VISTA AmeriCorps*NCCC AmeriCorps State/National Program Name: Program Director: Direct Supervisor: Location: From: to CITY STATE MONTH/YEAR MONTH/YEAR DID YOU COMPLETE YOUR FULL TERM OF SERVICE? Yes No If not, why not? _ Have you ever served in the Peace Corps? Yes No Program Director: Direct Supervisor: Country: From: to MONTH/YEAR MONTH/YEAR DID YOU COMPLETE YOUR FULL TERM OF SERVICE? Yes No If not, why not? _ Have you ever served in the United States Armed Forces? Yes No Branch of Service: Type of Discharge: Discharge Date: MONTH/YEAR Are you currently a member of the ROTC, National Guard or Reserves? Yes No

6 EMPLOYMENT 15. List and briefly describe the last four positions you have held. Begin with the current or most recent and go back ten years. Include self-employment, internships/fellowships, home management, and full- or part-time paid or unpaid work experience (including DHS Work Experience Program, PITC, On the Job Training, etc.) Make sure you include the name of your supervisor and phone numbers where information may be verified. (You may attach a resume instead only if it addresses the information requested below.) Name and Address of Employer Dates Job Title and Duties A. Organization-City/State From: / Title: Supervisor and Phone: To: / Duties: Reason for leaving: Hours/week: B. Organization-City/State From: / Title: Supervisor and Phone: To: / Duties: Reason for leaving: Hours/week: C. Organization-City/State From: / Title: Supervisor and Phone: To: / Duties: Reason for leaving: Hours/week:

7 Name and Address of Employer Dates Job Title and Duties D. Organization-City/State From: / Title: Supervisor and Phone: To: / Duties: Reason for leaving: Hours/week: 16. Explain any period of time greater than six months not accounted for by work, school, military or national service: MOTIVATIONAL STATEMENT/ESSAY 17. Why do you want to join AmeriCorps? What could you contribute to AmeriCorps? What do you hope to gain from serving as an AmeriCorps member? If you need additional room, attach a separate sheet of paper and limit your response to 500 words. NOTE: YOUR MOTIVATIONAL STATEMENT ACCOUNTS FOR 49% OF YOUR APPLICATION SCORE. Spelling, grammar, personal insight, quality of thought and expression and analytical ability are taken into consideration. APPLICATIONS LACKING THIS INFORMATION WILL NOT BE CONSIDERED FOR ACCEPTANCE.

8 SKILLS AND EXPERIENCE 18. Listed below are skill areas that LEADS AmeriCorps finds useful and seeks in applicants. Indicate the skill areas in which you have had training or experience, including volunteer or community service experience, and indicate how you gained those skills. APPLICATIONS LACKING THIS INFORMATION WILL NOT BE CONSIDERED FOR ACCEPTANCE. EVEN IF YOU DO NOT HAVE A CERTAIN SKILL OR EXPERIENCE, PLEASE MARK THOSE RESPONSES WITH NA NOT APPLICABLE. Example: Counseling Dorm Advisor Career/Vocational Coaching Computers Counseling Education Fine Arts/Crafts Public Speaking Teaching/Tutoring Youth Development Case Management Communications Conflict Resolution/Mediation First Aid/CPR Needs Assessment Recruitment/Outreach Writing/Editing Other(specify) 19. Do you know or have you studied any language other than English? Yes No Language: Number of Years Studied or Spoken: Speaking Ability Poor Fair Good Excellent Writing Ability Poor Fair Good Excellent 20. In the space below or on a separate sheet of paper, provide any additional information related to your skills, experiences, community involvement, education or life experiences, or on the job trainings that may be helpful in evaluating your application.

9 LEGAL Answer the following questions fully. Existence of criminal conviction and/or adjudication may or may not, depending on the circumstances, disqualify you from consideration. However, any intentional misrepresentation or omission of that record lying or not telling the whole truth will disqualify you. Do not include minor traffic violations, divorce/legal separation or child custody proceedings. TULSA HOUSING AUTHORITY WILL CONDUCT A STATEWIDE BACKGROUND (OSBI), INTERNAL SECURITY (THA), AND APPLICANTS WILL BE CHECKED IN THE NATIONAL SEX OFFENDER PUBLIC REGISTRY AND CONDUCT REFERENCE CHECKS ON ALL FINAL CANDIDATES PRIOR TO ACCEPTANCE. 21. Have you ever been: Convicted of any criminal offense by a civilian court or military authorities? Yes No Adjudicated or held responsible as a juvenile offender of any criminal offense by a civilian court or by authorities? Yes No Are you now: Under charges for any offenses or are any civil suits or judgments pending against you? Yes No On probation or parole? Yes No If no, skip to Certification on the next page. If you answered yes to any of the questions above, please provide the following information: Date: Place: MONTH/DAY/YEAR CITY STATE Charge: Action Taken: Court, Probation or Parole Officer: Phone: ( ) NAME AREA CODE Address: STREET ADDRESS CITY STATE ZIP CODE You may attach any additional information or explanation on a separate sheet of paper.

10 CERTIFICATION Your application must be certified with your original signature in ink. Please read the statement carefully before signing. UNSIGNED APPLICATIONS AND APPLICATIONS WITH PHOTOCOPIED OR FAXED SIGNATURES WILL NOT BE CONSIDERED FOR ACCEPTANCE. 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. I understand that misinformation or omission of information could result in disqualification and/or termination as an AmeriCorps member. I also understand that my selection for participation in the LEADS AmeriCorps program will require background, security and reference checks. I understand the Housing Authority of the City of Tulsa may, at its discretion and expense, require a physical examination, including drug and alcohol testing, and may, at any time, require drug and alcohol testing during my term of service. PRIVACY ACT NOTICE: The Privacy Act of 1974 (5 U.S.C. 552a) requires that the following notice be provided to you: The authority for collecting information from you in this application is contained in 42 U.S.C and of the National and Community Service Act of 1990 as amended, and 42 U.S.C of the Domestic Volunteer Service Act of 1973 as amended. You are advised that submission of the information is entirely voluntary, but the requested information is required in order for you to participate in AmeriCorps programs. The principal purpose for requesting this personal information is to process your application for acceptance into the LEADS AmeriCorps program, and for other general routine purposes associated with your participation in the LEADS AmeriCorps program. These routine purposes may include disclosure of the information to federal, state, or local agencies pursuant to lawfully authorized requests, to present and former employers, references provided by you in your application, and educational institutions, for the purpose of verifying the information provided by you in your application. The information may also be provided to federal, state, and local law enforcement agencies to determine the existence of any prior criminal convictions. The information will not otherwise be disclosed to entities outside the Tulsa Housing Authority, AmeriCorps and the Corporation for National Service without your prior written permission. SIGNATURE DATE

11 OPTIONAL INFORMATION This information will be used for statistical purposes and will not be used in the evaluation of your application. It will in no way affect your selection into AmeriCorps. Completion of this section is voluntary; failure to respond will in no way affect your candidacy. HOW DID YOU HEAR ABOUT THE LEADS AMERICORPS PROGRAM? Check all that apply. AmeriCorps representative (Career fair, conference, information session) Armed Forces College Career Guidance Office Current or former AmeriCorps member Department of Education Friend/Relative High school guidance counselor Internet/Listserv/ Newspaper/Magazine Article Newspaper advertisement Peace Corps Other service organization Radio advertisement Radio story Received information in the mail Television advertisement Television news story Poster at school Flyer Other (specify): WHAT IS YOUR ETHNICITY? Hispanic or Latino Not Hispanic or Latino WHAT IS YOUR RACE? Mark all that apply: Native American. A person having origins in any of the original peoples of North and South America (including Alaska and Central America) and/or 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, including, for example, Cambodia, China, Hong Kong, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Taiwan, Thailand, and Vietnam. Black or African American. A person having origins in any of the black racial groups of Africa. Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. White. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Other:

12 REFERENCES TO THE APPLICANT: Please supply the names, addresses and telephone numbers of two (2) people who have known you for at least one year who are not related to you by blood or marriage. The two references are an important part of your application. Select people that you know well who are familiar with your personal background, education, employment, and/or professional skills. Your references should be someone other than a family member or a peer not a classmate, a coworker, or a friend. Relatives are not considered credible references. Consider people from any of the following categories: A professor, instructor, teacher, advisor or school counselor, Your most recent job supervisor, volunteer supervisor, or other employer, A clergy person, mentor, coach, or someone else who is familiar with your community involvement and extracurricular activities. Note: Please get permission from these persons to use them as references, and let them know they can expect a telephone call from the THA AmeriCorps office. We MUST have an accurate telephone number for each reference! Name: LAST FIRST MIDDLE Position/Title: Organization/Institution: Address: (IF P.O. BOX, ALSO GIVE NUMBER AND STREET) CITY STATE ZIP CODE Home Phone: Work Phone: (INCLUDE AREA CODE) (INCLUDE AREA CODE) Name: LAST FIRST MIDDLE Position/Title: Organization/Institution: Address: (IF P.O. BOX, ALSO GIVE NUMBER AND STREET) CITY STATE ZIP CODE Home Phone: Work Phone: (INCLUDE AREA CODE) (INCLUDE AREA CODE)

13 APPLICANT DRIVERS LICENSE INFORMATION (Please Print. APPLICATIONS LACKING THIS INFORMATION WILL NOT BE CONSIDERED FOR ACCEPTANCE). Name LAST FIRST MIDDLE Address (IF P.O. BOX, ALSO GIVE NUMBER AND STREET) CITY STATE ZIP CODE Driver s License Number: Expiration Date: Do you have a valid State of Oklahoma Drivers License? Yes No I, the undersigned Applicant to the LEADS AmeriCorps Program, understand that the information provided above is to be used for the purpose of obtaining a Motor Vehicle Report (MVR) on my personal driving record. SIGNATURE DATE AUTHORIZATION TO RELEASE INFORMATION I hereby give my permission to the Housing Authority of the City of Tulsa (THA) or its agents to verify any information necessary pertaining to my application to the LEADS AmeriCorps Service Program, and authorize each school, employer, or reference named to confidentially give any pertinent information which may be requested. PRINTED NAME SOCIAL SECURITY NUMBER SIGNATURE DATE CRIMINAL HISTORY RECORDS AUTHORIZATION I hearby authorize Tulsa LEADS AmeriCorps to conduct a State Criminal Registry Check and a National Sex Offender Public Registry Check for my prospective participation in an AmeriCorps program. I realize that my selection to participate as an AmeriCorps member is contingent on the results of the background checks mentioned above. PRINTED NAME SOCIAL SECURITY NUMBER SIGNATURE DATE

14 LEADS AmeriCorps Housing Authority of the City of Tulsa P.O. Box East Independence Street Tulsa, OK Phone: (918)