Campus Ambassadors Mailing Address Form

OMB control number: 0420-0565
Expiration date: Sept. 30, 2021

If the above form is not appearing for you or is having issues, please use this form.


Privacy Act Statement: The Peace Corps, an agency of the federal government, is required by the Privacy Act of 1974 (5 U.S.C. 552a) to advise you of the following information regarding this form. The Privacy Act addresses the federal government’s use of certain personal information in agency files.

Authority: This form is authorized by the Peace Corps Act (22 U.S.C. 2501 et seq.) as amended.

Purpose: The information you provide will be used is to evaluate your suitability and qualifications to serve as a Peace Corps Campus Ambassador .

Routine Uses: The information you provide may be used for the routine uses described in the Privacy Act, 5 U.S.C. 552a, and the Peace Corps' published Routine Uses A through N, as defined in the Peace Corps' System of Records PC-10, PC-17, and PC-18. Routine Uses A through N are listed on the Peace Corps Privacy webpage.

Disclosure: The completion of this form is voluntary. However, failure to complete the form will result in the Peace Corps being unable to assess your qualifications and may preclude your consideration for the Peace Corps Campus Ambassador Program .

Paperwork reduction notice: Public reporting burden for this information collection is estimated to average 5 minutes. This includes the time for reviewing instructions and completing the information. This is voluntary information collection. An agency cannot conduct or sponsor and persons are not required to respond to, a collection of information unless it displays a valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: Peace Corps FOIA officer, 1275 1st St NE Washington D.C. 20526.

PC-2196 (Rev May 2021)