Distinguished Service Award Nomination Application

Distinguished Service Award Nomination

State FFA Application
Application Information
This form is to make a nomination for the State Distinguished Service Award. One nomination can be made per chapter per year.The State FFA Executive Board can nominate up to two organizations, agencies, business or other groups and up to two recipients will be selected through chapter nominations. State Distinguished Service is for organization, agencies, businesses, or other groups.

THIS APPLICATION MUST BE COMPLETED BY AN ADVISOR.
Date of Convention to be Awarded*

MonthDayYear
Date

Individual Information

This information pertains to the Chapter Advisor completing this form. All information on this page is in relation to the chapter FFA advisor.
Name*

First NameMiddle NameLast Name
Personal Phone*
Personal Email*
School & Chapter Information
School Name*
School Phone*
School Address

Street Address

Street Address Line 2

CityState

Zip Code
Chapter Name*
Chapter Number*

Award Information
App Year Date String
App Year FINAL
You are submitting a Distinguished Service Award Nomination for the application year

{appYear}
Name of Nominated Organization*
Organization, Agency, Business, Industry, etc.
Address of Nominated Organization*

Street Address

Street Address Line 2

CityState

Zip Code
Main Contact at Organization*

PrefixFirst NameLast Name
Title of Main Contact*
Email of Main Contact*
Be sure this email is used by the contact.
Phone Number of Main Contact*
Nomination Writing
Explain major contributions made to the Ag Ed Program/FFA Chapter*

min. 60 words/max. 180 words0/180
Discuss contributions made to local chapter which impact the State FFA Association*

min. 60 words/max. 180 words0/180
Advisor Certification
Advisor Key*
Use the Advisor Key provided by the State to access the signature section.
Certification*

I certify that I am the advisor to the chapter named on this application form and have provided my signature below.
Advisor Signature*

Clear

Submit

This is for FINAL SUBMISSION only. If you wish to edit your responses at a later time, DO NOT click submit.
Should be Empty:

Application Information