Connected Communities AmeriCorps Program Application

for any questions, please contact Maya Crane, 585-224-1083,

Full Name (First and Last) *
Full Name (First and Last)
Birth Date *
Birth Date
Your Address *
Your Address
Home Phone *
Home Phone
Cell Phone
Cell Phone
Work Phone
Work Phone
Are you currently employed? *
If currently employed, select one:
Present Employer's Phone Number
Present Employer's Phone Number
Have you lived outside New York State within the last five (5) years? *
Please also include level (fluent, conversational, limited, basic...etc)
Have you been convicted of a crime as an adult? *
(A conviction will not bar you necessarily from becoming an employee)
Do you hold a valid driver's license? *
Do you consent to a routine background check consisting of criminal, history, and sex offender records? *
Please include their full name (first, last), address, phone, relationship to you.
Please enter your full name and date below, which will serve as your electronic signature.