EmailMe Form - VHCB AmeriCorps Member Intent to Commit 23-24

Legal Name *

First Last

Preferred Pronouns

Preferred Name

Social Security Number
(required for AmeriCorps Portal enrollment) *

By signing this intent to commit, you: *

are entering into a good faith agreement to fulfill an AmeriCorps term in the Vermont Housing & Conservation Board AmeriCorps Program

are certifying that you are not required to be listed on the National Sex Offender Registry and have not been convicted of murder

agree to undergo a National Service Criminal History Check and understand that eligibility to serve in VHCB AmeriCorps is contingent on results of the background check.

Please attach a copy of a photo ID to verify your legal name for the National Service Criminal History Check.

Please attach your completed AHS Abuse Check Release

Form can be accessed at: https://www.vhcb.org/sites/default/files/programs/americorps/AHS%20Abuse%20Check%20Release.pdf

Date and location of scheduled fingerprint collection for Fieldprint Criminal Background Check:

(must be scheduled prior to signing this form)
https://fieldprintcncs.com/

Fingerprinting Date *

Fingerprinting Location *

Include name of Business and Town/State

For criminal background check purposes, please write the state in which you were residing in at the time you submitted your AmeriCorps application: *

Signature *

Clear

Date *

MM / DD / YYYY