Requirements for Acceptance:

1. Confine narrative to one page.
2. Add existing reporting evidence.
3. Use standard type; do not reduce.

Date:___________________________

Name:___________________________ SSN:____________________________

Title:__________________________ County:__________________________

Time of Service (as of Dec. 1, this year): Years_____Months_____

Date of First Appointment:___________________________

Date of Hire as a 4-H Agent: _________________________

Number of years as a NCAE4HA member:_____________________

Degrees: BS___BA___MA___MS___Other____Yr. Completed___________

A. Fifty words to be read during award's presentation:

Nominator's Signature ________________________________ Date _____________