A Certifying Organization

PRESIDENT'S VOLUNTEER SERVICE AWARD - FORM A
CERTIFYING ORGANIZATION APPLICATION FORM
This form MUST be completed by any organization that is interested in
presenting the President's Volunteer Service Award . This form is for
first-time registrants only. Please fax completed forms to 1-202-729-8033.
If you would like to mail this form, please send it to the address at the bottom
of the page.
ORGANIZATION INFORMATION
NAME
ADDRESS
CITY
STATE
ZIP
PHONE
FAX
WEBSITE
CONTACT PERSON FOR YOUR ORGANIZATION
NAME
TITLE
ADDRESS
CITY
STATE
PHONE
EMAIL

ZIP

Is this an _____ Independent Organization or _____ Organization's Headquarters or _____ Chapter Location?
TYPE OF ORGANIZATION (please check all that apply)
Business
Government
College/ University
Human Services
Community Program
Labor Union
Faith-Based
National Service Org.
Fraternity/ Sorority
Nonprofit
Other (please specify) ___________________________

School
Service Club
State Commission
Volunteer Center
Youth Development Org.

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
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 the Citizen Corps
programs like Citizen Corps Councils, Neighborhood Watch, Medical Reserve Corps, Volunteers in Police Service and
CERT (Community Emergency Response Teams).
Global Health & Prosperity
Includes international volunteer efforts by American professional serving abroad through non-governmental organizations
and companies to share their skills in the following areas: agriculture, capacity building, economic growth, education,
HIV/AIDS prevention and treatment, health care, information technology, natural resources, clean water, women
& youth empowerment.

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.

Mail to: Points of Light Foundation/ PVSA
1400 I Street, N.W. Suite 800
Washington DC 20005

OMB Control #: 3045-0086
Expiration Date: 02/28/2007
See reverse for Public Burden Statement and Privacy Act Notice.

Public Burden Statement: The public burden for this collection of information is estimated to
average 20 minutes per submission, including reviewing instructions, gathering the data needed,
and completing the form. Comments on the burden or content of this instrument may be sent to
the Corporation for National and Community Service, Office Public Affairs, 8th Floor, Attn: Ms.
Rhonda Taylor, 1201 New York Avenue, N.W., Washington, D.C., 20525. The Corporation
informs people who may respond to this collection of information that they are not required to
respond to the collection of information unless the OMB control number and expiration date
displayed are current and valid. (See 5 C.F.R.1320.5(b)(2)(i)).
Privacy Act Notice: The Privacy Act of 1974 (5 U.S.C. 552a) requires that the following notice
be provided to you. The authority for collecting this information is contained in Executive Order
13285, signed January 29, 2003. The principle purpose for collecting this information is to
recognize individuals, schools and organizations that excel in their efforts to support volunteer
service and civic participation, especially with respect to students in primary and secondary
schools, and institutions of higher learning. The information will be used to select winners of the
President’s Volunteer Service Awards and the Call to Service Awards. Nominations for these
awards are voluntary. All information that is provided to the Corporation and its administrating
organization will not otherwise be disclosed to entities outside of the Corporation without the
approval of the individual or organization nominated for the award.

Instructions for FORM A (Certifying Organization Application Form)
All President’s Volunteer Service Awards must be verified and issued through institutions which
we call Certifying Organizations (CO). CO may include faith-based institutions, schools, higher
education, nonprofit and community-based organization, businesses, labor unions, civic or service
clubs, membership and trade associations, and federal, state or local government agencies. This
form is for first-time CO registrants.
To qualify as a CO, an organization must:
• Be legally established and located within the United States, the commonwealth of Puerto
Rico, or a United States territory;
• Agree to review and verify the records of service of prospective individual and
family/group recipients, and then distribute the award only to those who meet the
established criteria;
• Either directly or through sponsorship pay for each Award package that it requests.
Organization Information:
Please fill out organizational information, giving full address, including city, state and zip, phone
number, and website if available.
Contact Person:
It is important to fill in information for the person responsible for coordinating and submitting
nominations and order forms. Please include email address.
Please indicate whether your organization is an independent organization, an organizational
headquarters, or a local chapter location of a regional or national organization.
Type of Organization:
Please check the box or boxes that most appropriately describes your organization.
Primary Service Area:
Descriptive information under each category provides examples of appropriate activities. This is
meant to be descriptive rather than exclusive and describes some specific activities that would
qualify.
How many President’s Volunteer Service Awards do you plan to award? Please provide an
estimate of how many awards you plan to give out for each year. These numbers are meant only to
help plan for future years. Providing these numbers does not obligate your organization in any
way!
Optional Information:
Number of volunteers active with your organization annually? Please provide an estimate of the
number of volunteers who participate in your organization. This number will include ongoing
volunteers as well as those who participate only in special projects.
Is your organization a membership organization? Please indicate if your organization has a formal
membership or affiliate program.