Fillable Form 1: AMERICORPS NATIONAL CIVILIAN COMMUNITY CORPS (NCCC) (Corporation for National & Community Service)

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Form 1: AMERICORPS NATIONAL CIVILIAN COMMUNITY CORPS (NCCC) (Corporation for National & Community Service)

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AMERICORPS NATIONAL CIVILIAN COMMUNITY CORPS (NCCC)
PROJECT CONCEPT FORM (PCF)
1
OMB Control Number: 3045-0010
Expiration Date: 10/31/2022
APPLICATION INFORMATION
1
Organization Name
Mailing Address
City State ZIP
Office Telephone Ext.
Secondary Sponsor
Organization Name
Mailing Address
City
State
ZIP
Office Telephone
Ext.
2 EIN
Secondary
Sponsor EIN
•
Community-Based Nonprofit Organization
•
National Nonprofit
•
Federal Government
•
School
3 Organization Type
•
Indian Tribe
• State Government
•
Local Government or Municipality
4
Authorized
Representative
Organizational Title
Phone Number Ext.
Email Address
PROJECT INFORMATION
5
Project Start Date
Fixed or Flexible?
Project End Date
Fixed or Flexible?
Estimated Completed
Time (Weeks)
OTHER
I am an NCCC alum.
From an AmeriCorps State or VISTA member.
I am a past NCCC Sponsor.
From a community partner.
6
How did you
hear about
AmeriCorps
NCCC?
I am a past NCCC Staff member.
From an NCCC alum.
From an NCCC Staff member.
From a current NCCC member.
From a state CNCS office.
By email.
On social media (e.g. Facebook, Twitter,
Instagram, YouTube, LinkedIn).
On the CNCS Website.
Other
OTHER (CONTINUED)
7
Is your organization currently funded wholly or in part by the Corporation for
National and Community Service?
Yes No
If ‘Yes,’ is the proposed project funded by
grant or any AmeriCorps VISTA resources?
an AmeriCorps State and National
Yes No
If ‘Yes,’ to either of the above questions, please provide detailed information concerning the funding
those funds.
source and utilization of
8
Will the
current
proposed service
or projected staff
replace any of your organization’s
or contracted labor?
Yes No
ADDITIONAL QUESTIONS
Has your organization previously
AmeriCorps NCCC team?
sponsored an
Yes No
9
If ‘Yes,’ how many
organization?
teams have served with your
If ‘Yes,’ when did
organization?
a team most recently serve with your
10
Has your organization ever had a “Fee-for-Service”
arrangement with a Youth Corps or Conservation Corps
program?
Yes No
If ‘Yes,’ AmeriCorps NCCC has effectively been used in past projects to augment and support existing Youth
Corps partnerships with organizations. Please describe how you plan to utilize the AmeriCorps NCCC team with
your existing partnership with the “Fee-for-Service” Corps.
PROJECT FOCUS AREAS
Energy Conservation
Environmental Stewardship and Conservation
11
Primary Area of
Community
Need
Infrastructure Improvement
Natural and Other Disasters
Urban and Rural Development
2
AMERICORPS NATIONAL CIVILIAN COMMUNITY CORPS (NCCC) OMB Control Number: 3045-0010
PROJECT CONCEPT FORM (PCF) Expiration Date: 10/31/2022
12 Need
3
NARRATIVES
AMERICORPS NATIONAL CIVILIAN COMMUNITY CORPS (NCCC)
OMB Control Number: 3045-0010
PROJECT CONCEPT FORM (PCF) Expiration Date: 10/31/2022
4
Project Design
13
AMERICORPS NATIONAL CIVILIAN COMMUNITY CORPS (NCCC)
OMB Control Number: 3045-0010
PROJECT CONCEPT FORM (PCF) Expiration Date: 10/31/2022
PRIMARY LOCATION OF SERVICE
Organization
Street Address
Address Line 2
City State ZIP
Accessible for people
14
Yes No
with disabilities?
Site Supervisor Name
Organizational Title
Email Address
Phone Number
PRIMARY LODGING SITE
Lodging Provider
Anticipated Arrival Date Anticipated Departure Date
Apartment or Condo
Hotel
Armory
Military Facility
Bed and Breakfast
NCCC Campus
Cabin
Recreational Vehicle
Campsite
School Room or Classroom
Type of Lodging
Church or Other Faith-Based
Trailer
Organization
Vacant Home
15
Community Center
Volunteering Housing
Dorm
Yurt
Homestay
Other
Hostel
Local Government or
Community or Faith-Based
Municipality
Organization
Military
Federal Government
Lodging Category
National Nonprofit Organization
Indian Tribe
National or State Park
Institute of Higher Education
Other
5
LOCATIONS
AMERICORPS NATIONAL CIVILIAN COMMUNITY CORPS (NCCC) OMB Control Number: 3045-0010
PROJECT CONCEPT FORM (PCF) Expiration Date: 10/31/2022
Street Address
Address Line 2
City State
ZIP
Accessible for people
with disabilities?
Yes No
Beds provided?
Yes No
F
ull Kitchen (including
stove and fridge) on site?
Yes No
If no full kitchen,
microwave oven
on site?
Yes No
Showers on site?
Yes No
Laundry on site?
Yes No
Please use the space provided below to further describe team lodging accommodations.
PRIMARY LODGING SITE (CONTINUED)
15
SIGNATURE
The Project Concept Form must be signed by a representative of the sponsoring organization.
An electronic signature will be accepted.
Project Sponsor Signature
_______________________
Date
________
_______________________________________
AMERICORPS NATIONAL CIVILIAN COMMUNITY CORPS (NCCC) OMB Control Number: 3045-0010
PROJECT CONCEPT FORM (PCF) Expiration Date: 10/31/2022
6
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Form 1: AMERICORPS NATIONAL CIVILIAN COMMUNITY CORPS (NCCC) (Corporation for National & Community Service)

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Completed 14 February 2021

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