APPLICATION FOR EMPLOYMENT

Submit: 1) a completed application form, 2) a résumé or CV, 3) Cover letter to the Peace Corps Georgia office,
118 Sairme Street, Tbilisi, or email it to GE-vacancy@peacecorps.gov

1. Job title in announcement 2. Last Name 3. First and Middle Names

4. Mailing address: 5. Email Address: 6. Phone Numbers:

Daytime:
7. Date of birth (month, day, year) 8. Place of Birth (town)
Evening:
Cell phone:

9. Education (list colleges and university attended beginning with the most recent)
Name of School Degree/Diploma Month/Year Awarded

10. Work Experience (describe your paid and non-paid work experience related to the job your are applying for)
A. Job title (if federal include series and grades)
Employers name and address:
Immediate supervisor’s name and phone number
Dates employed (MM/YY – MM/YY)
Salary per
Reason for leaving
Description of work (describe your specific duties and accomplishments)

B. Job title (if federal include series and grades)

Employers name and address:
Immediate supervisor’s name and phone number
Dates employed (MM/YY – MM/YY)
Salary per
Reason for leaving
Description of work (describe your specific duties and accomplishments)
C. Job title (if federal include series and grades)
Employers name and address:
Immediate supervisor’s name and phone number
Dates employed (MM/YY – MM/YY)
Salary per
Reason for leaving
Description of work (describe your specific duties and accomplishments)

We may contact your supervisors for a reference.

11. When can you start work?
12. Languages you speak or read other than Georgian. List each language and place an “X” in each column that
applies to you
Language Speak Read Write Translate

13. List special qualifications, skills or accomplishments that may help you to get a job. Some examples are: skills
with computers or other machines; most important publications (do not submit copies); etc. Give the title and
year of honors or awards you have received

14. Relatives (mother, father, brother, sisters, spouse, children)

Name Relationship Occupation

15. References. List two people who are not related to you and do not supervise you, who know your
qualifications for the job for which you are applying.
Full name of reference Telephone number(s) Present business or home address

 A false statement on any part of your application may be grounds for not hiring you, or for firing you after you
begin work.
 I understand that any information I give may be investigated as allowed by law or Presidential Order.
 I certify that, to the best of my knowledge and belief, all my statements are true, correct, complete, and made in
good faith.

SIGNATURE ........................................................ DATE (Month/Day/Year) ..........................................

MS 611

Attachment A
April 2, 1984
PEACE CORPS

INTELLIGENCE BACKGROUND INFORMATION

The following information is required by Peace Corps Manual Section 611 entitled "Eligibility for Peace Corps
Employment or Volunteer Service of Applicants with Intelligence Backgrounds" (See reverse side for eligibility
policy).

Have you ever been employed by any intelligence organization or otherwise engaged in or been connected with
intelligence related activities?

Yes _____ No _____

If yes, explain below giving dates, nature of connection, and other details.

ATTENTION
I have completed this Statement with the knowledge and understanding that all items contained herein may be
subject to investigation and verification prescribed by law or regulation.

I have read the paragraph relating to eligibility for a position as an employee, expert, consultant, or personal services
contractor with the Peace Corps, MS 611, Part 4, which appear on the reverse side of this form. I understand that a
false answer or false information may be grounds for not employing me or for dismissing me after I have been hired,
and may be punishable by fine or imprisonment (US Code, Title 18, Section 1001).

CERTIFICATION
I certify that all of the statements made by me are true, complete, and correct to the best of my knowledge and
belief, and are made in good faith.

SIGNATURE ........................................................ DATE (Month/Day/Year) ..........................................