Americorps Vista Member Registration Form
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1AmeriCorps VISTA Member Registration Form
1. N
2. D
B
AME (LAST NAME, FIRST NAME,
ATE OF
IRTH (mm/dd/yyyy)
MI)
3. CNCS S
O
TATE
FFICE
4. D
E
D
ATE
NTERED ON
UTY
5. N
K
E
C
EXT OF
IN
MERGENCY
ONTACT
Full Name: ________________________________________________________
Phone Number: ( ) _____ - _________ Relationship: ______________________
Street Address: _____________________________________________________
City, State, Zip Code: ________________________________________________
6. OATH OF SERVICE
The following oath or affirmation of service is required by the Domestic Volunteer Service Act of 1973, as
amended, and must be administered by an authorized staff member of the Corporation for National and
Community Service:
I do solemnly swear (or affirm) that I will support and defend the Constitution of the United
States against all enemies, foreign and domestic; that I will bear true faith and allegiance to
the same; that I take this obligation freely, without any mental reservation or purpose of
evasion; and that I will well and faithfully discharge the duties of the office on which I am
about to enter. So help me God.
Member’s signature________________________________ Date__________
*NOTE: The phrase “So help me God” and the word “swear” wherever it appears in the oath may be
stricken when the Member elects to “affirm” rather than swear to the oath; only these words may be stricken
and only when the Member elects to affirm the Oath of Service.
7. PROVISO
I understand that my assignment is contingent upon my successfully completing a criminal
background check. Should a background check show that I am ineligible to serve in the
VISTA program for any reason, I will be terminated from service and forfeit all service
benefits.
Member’s signature________________________________ Date__________
8. FOR OFFICAL USE ONLY
Subscribed and sworn to (affirmed) before me this _________ day of _______, _________
Signature______________________________________ Title ______________________
Revised January 2011
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