2010 – 2011 APPLICATION

Instructions: Please print using black or blue ink and make sure to attach a résumé and
cover letter with your application.

Personal Information:

Name: ____________________________________________________________
Last First Middle Initial
Address: ___________________________________________________________
Street Apt.
____________________________________________________________
City State Zip Code

Home Phone: ( ) _______- __________

Cell Phone: (____) _______-___________ Do you have text messaging? _________

Email: _________________________________@__________________.com

Social Security Number: _________-___________-___________

Date of Birth: ________ / __________/ ________ Sex: _______M _______F

Month Day Year

Are you a U.S. citizen or resident alien? _______Y ______N

*All applicants MUST show proof of citizenship or residence to be considered. United States
passports and birth certificates or INS form I-551(Green Card) are acceptable documents.

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New York Juvenile Justice Corp Application 2010

Legal Information:
It is very important to be honest in this section. A criminal record does not necessarily
disqualify you from consideration for the Juvenile Justice Corps; however, misrepresentation of
a criminal record will disqualify you. A background criminal history check on all members will
be completed before the service term begins. Your answers will be kept completely confidential.

Have you ever been convicted of any crime other than a minor traffic violation?
____Yes ____No
If yes, please indicate why, when and where you were convicted. Please include juvenile
offenses.
______________________________________________________________________________
______________________________________________________________________________
________________________________
Do you have any pending charges or are you under any type of criminal investigation?
___Yes ____No

If yes, please explain:

______________________________________________________________________________
______________________________________________________________________________
_________________________________

Are you currently on probation or parole? ____Yes ____No

If yes, please provide the name and phone number of the judge or probation/parole officer that
we can contact to verify the above information:
Name:___________________ Title:_____________ Phone: ( )___________

Victimization
Because New York Juvenile Justice Corps members may be asked to do hands-on work with
victims, we are interested in learning if you have any first-hand experience with victimization.
Your response is strictly optional and will in no way affect your application. Again, your
answers will be kept completely confidential.

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New York Juvenile Justice Corp Application 2010

Have you ever been the victim of a crime? ____Yes _____No

If yes, what were the circumstances?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Member Profile
Please describe your ethnic background. Your response is optional and will in no way affect your
application.

_____ African American _____Asian or Pacific Islander ____ Caucasian

______Hispanic/Latino ______Native American ______Other

Do you have any special needs that require accommodation? ____Yes ___No
If yes, please specify:
______________________________________________________________________________
______________________________________________________________________________

References
Please provide contact information for two references that we may contact. Your reference may
be a former employer, a community leader, a teacher, a coach or clergy: it may not be a relatives
or a peer.

1. Name: ______________________ Position: ________________________

Address:
____________________________________________________________________________
____________________________________________________________________________

Phone Number: ( )_______________________

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New York Juvenile Justice Corp Application 2010

(References Continued)

2. Name: ______________________ Position: ________________________

Address:
____________________________________________________________________________
____________________________________________________________________________

Phone Number: ( )_______________________

Certification
I hereby certify that the information on this application, and my attached resume and Doctor’s
note, is true and correct to the best of my knowledge. I understand that any information or
omission of information could result in unfavorable consideration or immediate dismissal. I
allow release of this information for verification and evaluation purposes only.

Signature: ___________________________ Date: ________________

END OF APPLICATION

New York Juvenile Justice Corps is An AmeriCorp Service Program,

a project of the Center for Court Innovation, in collaboration with the Office of Children and
family Services and the John Jay College of Criminal Justice

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