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Certifying Organization Application Form

This form MUST be completed by any organization that is interested in presenting the President's Volunteer Service Awards. All the information requested is required, except if it is labeled as optional. Click here for instructions

ORGANIZATION INFORMATION
ORGANIZATION NAME*
STREET ADDRESS*
CITY*
STATE*	-- AB AK AL AR AZ BC CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MB MD ME MI MN MO MS MT NB NC ND NE NF NH NJ NM NS NT NV NY OH OK ON OR PA PE QC RI SC SD SK TN TX UT VA VT WA WI WV WY YK
ZIP*
PHONE*
FAX
WEBSITES

CONTACT PERSON FOR YOUR ORGANIZATION
	SAME ADDRESS AS ABOVE
FIRST NAME*
LAST NAME*
TITLE
STREET ADDRESS*
CITY*
STATE*	-- AB AK AL AR AZ BC CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MB MD ME MI MN MO MS MT NB NC ND NE NF NH NJ NM NS NT NV NY OH OK ON OR PA PE QC RI SC SD SK TN TX UT VA VT WA WI WV WY YK
ZIP*
PHONE*
EMAIL*
Is this an: Independent Organization or Organization's Headquarters or Chapter Location ?

TYPE OF ORGANIZATION * (please check all that apply)
Business	College/University
Community Program	Faith-Based
Fraternity/Sorority	Government
Human Services	Labor Union
National Service Org.	Nonprofit
School	Service Club
State Commission	Student Council
Volunteer Center	Youth Development Org.
Other (please specify)

PRIMARY SERVICE AREA(s) *
		Youth Achievement Includes volunteer activities such as mentoring, coaching, tutoring, improving literacy in areas such as reading and finance, and volunteering to keep young people engaged academically in education.
		Parks and Open Spaces Includes volunteer efforts to conserve and protect our parklands and gardens, neighborhood cleanups and creating safe playgrounds. It also includes creating safe and meaningful experiences and outdoor activities for individuals to enjoy the environment and our natural resources.
		Healthy Communities Includes volunteer efforts to help the elderly, disabled, diseased, hungry or homeless, and to improve the economic health of the community. These could include volunteering for health and nutrition education services, immunization campaigns, resume building, career training, disease screenings, hospital support, blood drives, veterans outreach, working with local public health programs, micro-enterprise and business development.
		Public Safety & Emergency Response Includes volunteer efforts for individuals and families to make their homes, and their communities safer from the threats of crime, terrorism, and disasters of all kinds. It includes preparedness training, volunteer firefighters, and programs like Citizen Corps, Neighborhood Watch, Medical Reserve Corps and Volunteers in Police Service.

How many President's Volunteer Service Awards do you plan to award? *
		2006
		2007
		2008

Optional Information
Number of volunteers active with your organization annually?
Does your Organization have a formal membership program?  yes  no
Briefly describe the organization's focus or mission.

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Click on links for Public Burden Statement and Privacy Act Notice. Public Burden Statement  |  Privacy Act Notice OMB Control #: 3045-0086 Expiration Date: 02/27/2007