Revised 11/05

T. C. BLALOCK YOUNG AGENT AWARD

    Requirements for Acceptance:
  1. Confine all answers to space provided unless otherwise indicated.
  2. No supporting evidence, including letters of support or reference, are to be attached to this application.
  3. Use standard typed do not reduce.
  4. Complete and send ten copies to the NCAE4-HA District Recognition Chairman by date set.

To be completed by 4-H Extension Agent. Please type.

Check one:

____________Agent with 1-3 years 11 months 4-H experience as of Winter Professional Meeting.
____________Agent with 4-6 years 11 months 4-H experience as of Winter Professional Meeting.
(Time of service as of December 31 of current year: Years____ Months______

PURPOSE: The purpose of the North Carolina 4-H Agent Recognition Program is to recognize 4-H agents doing 4-H work in North Carolina for outstanding accomplishments, two with 1-4 years experience and two with 4-7 years experience based on the current years's work (Jan.1 - Dec.31)

1.NAME:__________________________________________________________

OFFICE ADDRESS:_________________________________________________ _________________________________________________________________ _________________________________________________________________

COUNTY:__________________________

DATE OF HIRE AS A 4-H AGENT: _________________________________

2. DEGREES - BS______BA_____MS____List Other____________________

3. Total County Population ___________________________

Total Youth Potential_______________________________

Total Youth Reached in current year____________________

Percent of time applicant does 4-H _____________________

Number of co-workers who do 4-H______________________

Number of 4-H Assistants/Associates____________________



4. PROGRAM ACCOMPLISHMENTS

Briefly describe your most outstanding accomplishments this year. (Limit to two pages)











5. PROFESSIONAL IMPROVEMENT - Give evidence of professional growth through credit or non-credit courses, work toward advanced degree, professional association meetings, travel study, etc.












6. SPECIAL HONORS AND AWARDS







7. PROFESSIONAL ASSOCIATION MEMBERSHIP AND PARTICIPATION

A.District 4-H Agents Association. List Offices, Committees, Chairmanships, Annual Meetings attended and Winter Professional Meetings Attended (Include Dates)







B. State 4-H Agents Association. List Offices, Chairmanships, Annual Meetings attended and Winter Board Meetings attended. (Include dates)







C. National 4-H Agents Association. List Offices, committees, Chairmanships, Annual Meetings attended. (Include dates)







c. List current membership in related Professional Associations and Offices, Chairmanships held. (Include dates)








8. Person submitting application:_____________________________

DATE:

District Recognition Chairman:_____________________________



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