NAME: _____________________________________________________ DATE: __________

OFFICE ADDRESS: __________________________________________PHONE: ________

_____________________________________________________________ ZIP:____________

COUNTY: __________________________________YEARS OF SERVICE:______________

HOURS WORKED PER WEEK:____________________

Paraprofessional with 1-3 years 11 months experience as of upcoming Winter Professional Meeting _____________________

Paraprofessional with 4-6 years 11 months experience as of upcoming Winter Professional Meeting _____________________

Paraprofessional with 7 years or more experience as of upcoming Winter Professional Meeting______________________

PURPOSE The objective of the North Carolina Program Assistant Recognition Program is to identify and recognize those Program Assistants/Associates whose efforts and initiative have been responsible for producing outstanding new 4-H programs, expanding enrollment of members and leaders, and other significant contributions in 4-H programming. Must be current year's work.

NOTE: This nomination is to be completed and signed by the supervising 4-H agent.

1. Attach a narrative, not more than 500 words, describing the program assistant's most outstanding accomplishment. Include audience, methods, materials, resources, evaluation techniques, and accomplishments (impacts).

2. The major "thrusts" and audiences for which the program assistant assumes major responsibilities.

Eight copies of this form should be sent to the District Recognition Chairman

Recommended by

Signature District Recognition Chairman