corps member application alejandro balcazar

8/8/2019 Corps Member Application ALEJANDRO BALCAZAR

http://slidepdf.com/reader/full/corps-member-application-alejandro-balcazar 1/4

Corpsmember Application

Date: 12 Sep 2010

Please print or type clearly. Name: BALCAZAR ALEJANDRO MONTALVO

(Last) / / Age 23

(First) Male X

(Middle) Female

yes no

Date of Birth: 11 12 1986 Are you a United States citizen, national, or lawful permanent resident alien? x Do you have a high school diploma or GED certificate? x yes no

Current Address:

572 Regimiento 24 Street

Santa Cruz de la Sierra Santa Cruz

Number and Street City State Zip Phone (where we can reach you): ( 591 Email: [email protected]

)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)

website



Please answer on a separate piece of paper: 1. 2. 3. 4. 5. 6. 7. 8.

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? What is an accomplishment you are proud of? What skills, people and/or experiences enabled you to succeed in the process? What experience do you have working with groups of people and/or serving in leadership roles? What are your main activities and interests? (i.e. studies, employment, community, hobbies, volunteer activities, etc.) 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? 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 situations? 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? 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.

9. 10. 11. 12.

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

If yes, please specify: noDo you have children who rely on you as their primary caretaker or for financial support?

Yesno no

no

2



Required Legal Information

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 violations.

Have you ever been: Convicted of any criminal offense by a civilian court or by military authorities? Yes______No____X___

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

Are you now: Under charges for any offenses or any civil suits or judgments pending against you? Yes_______No___X____

On probation or parole? Yes_______No_____X__

If no, skip the certification below. If you answered yes to any of the questions above, please provide the following information: Date: Charge: Court, Probation, or Parole Officer (Name): Phone: _____________________ Address: Number and Street City State Zip Code

/ / Place (City, State): Action taken:

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

3 Date



REFERENCES: 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

Address or Email Address: [email protected] Relationship to applicant: friend and youth leather

2. Name: Ivan Pinto Address or Email Address: [email protected] Relationship to applicant: working together.

Phone: 591 72112537

Phone: 591 76059969

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 E-mail: [email protected]

For EarthCorps Use Only: Date Received:/ Application Resume Reference 1 Reference 2 Other

4

corps member application alejandro balcazar

Documents