Montgomery County Conservation Corps
Corpsmember Application Form

PERSONAL INFORMATION DATE:____/______/_____

Name: __________________________________________________ SSN: _____- _____ - _____

Street: ___________________________________ APT#: _________ TEL# _________________

City: ______________________________________ MD ZIP CODE: ______________________

___ Male ___ Female Driver’s license: ___Y___N Date of Birth: ____/____/____

How Did You Learn About MCCC?

___ Newspaper ___ Poster/flyer ____ Bus Ad ___ School ___ Cable TV

___County employee ___Job recording ___Counselor ___ Corpsmember

______________________________________Other

EDUCATION INFORMATION

Highest grade completed (check one):

___Have GED ___High School Diploma __________ # of College Credits

Last School Attended:___________________________________________ State: ______

Date Left School: _____/_____/_____

EMPLOYMENT INFORMATION

Previous employment: ___3 years or more ___up to 2 years ___up to one year

___up to six months ___no work experience ___volunteer experience

LAST JOB

Employer Name: ________________________________________________________________

Street Address: ______________________________

City: ________________________________ State: ______________ Zip Code: __________

Supervisor’s Name & Title: ______________________________________________________

Telephone #: ________________________________

Dates of Employment:

Start Date: _____/_____/_____ End Date: _____/_____/_____

Wages: Start: $______________ End: $_______________

In one year: ____________________________________________________________________

________________________________________________________________________________

In five years: ___________________________________________________________________

________________________________________________________________________________

WHAT WOULD YOU WANT TO ACCOMPLISH IN THE CONSERVATION CORPS:

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Please FAX completed application to: Jeff Griffiths at (301) 929-5560.