Form CSREES-01 Application for Authorization to use the 4-H Name and/or

OMB Approved No. 00524-0034
Expires TBD

UNITED STATES DEPARTMENT OF AGRICULTURE
COOPERATIVE STATE RESEARCH, EDUCATION AND EXTENSION SERVICE
WASHINGTON, DC 20250
APPLICATION FOR AUTHORIZATION TO USE THE 4-H NAME AND/OR EMBLEM
(Under provisions of 18 U.S.C. 707 and 7 CFR Part 8)
Applications for authorization to use the 4-H Name and/or Emblem must be submitted to:
Administrator
Cooperative State Research, Education, and Extension Service
U.S. Department of Agriculture
4-H Name & Emblem Application
c/o 4-H National Headquarters
MAILING ADDRESS: 1400 Independence Ave, SW, MS 2225, Washington, DC 20250
SHIPPING ADDRESS: 800 9th St, SW, Room 4333, Washington, DC 20024
Or via email:
Email a signed, scanned/PDF copy of this form to [email protected]. Attach to the email a
graphics file depicting a sample of the product(s) and proposed use(s) of the 4-H Name and/or
Emblem.
If authorization is granted, the applicant will accept the authorization with the understanding that:
a. The 4-H Name and/or Emblem will be used only as specified in the application and/or
written authorization;
b. Authorization does not grant the applicant the exclusive right to the 4-H Name and/or
Emblem for this or any other purpose;
c. The Cooperative State, Research, Education and Extension Service may grant similar
authorizations to competing organizations; and
d. This authorization is revocable at the discretion of the Administrator, Cooperative State
Research, Education, and Extension Service, or their designee, at any time after written
notice.
Please complete page 2 of this application, including supplying a sample or graphic image of the
product(s) and proposed use(s) of the 4-H Name and/or Emblem.
By signing this form, the applicant acknowledges the federal legislation and regulations
concerning use of the 4-H Name and/or Emblem. Agreement is hereby made that, if authorization
is granted, the applicant will abide by all of the regulations therein.

(Name of Applicant – printed/typed)

(Signature of Applicant)

(Title)

(Date)

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0524-0034. The time required to
complete this information collection is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

CSREES-01 (_______) Page 1

OMB Approved No. 00524-0034
Expires TBD

APPLICATION
(Please type or print)

In certain situations, County or State Cooperative Extension Service/Land-Grant Institution authorization is required. Duly
authorized 4-H Clubs and County and State Cooperative Extension Services are among those authorized to use the 4-H Name
& Emblem for their own educational or informational purposes, so long as they are consistent with federal legislation and
regulations regarding the 4-H Name and/or Emblem. When using a vendor, the vendor needs to seek authorization to use the
4-H Name and/or Emblem at the appropriate level. Before completing this form, consider the following:
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Does this request originate with a duly authorized 4-H Club or County or State Cooperative Extension Service?
Is the proposed distribution of product(s)/service(s) confined to a specific county or state?
Do the proposed product(s)/service(s) identify the club, county, area, or State 4-H program?
Is the vendor, or any other providing product development, based within the county or state in which distribution is planned?
Is the vendor only working with 4-H within the specified county or state (and not working with 4-H elsewhere, either
simultaneously or consecutively)?

If you would answer yes to ALL of the above, please contact the appropriate County or State 4-H Office to inquire about their
procedures for securing authorization for the specified use for a specified period of time. Per regulations, CSREES reserves the
right to review and revoke any authorization or permission for use of the 4-H Name and/or Emblem at any time. If you would
answer no to ANY of the above, please continue.
Name of Individual, Partnership,
Corporation, or Association:
Name of Authorized
Representative:
Title of Authorized
Representative:
Organizational Address
(give complete mailing address):

Fax No. (inc.

Telephone No. (inc. area code):

area code):

Web Site:
E-mail
address:
Type of Request:

New

Renewal

Proposed use of the 4-H Name
and/or Emblem (be specific):

Length of time authorization
requested:
Plan for sale OR distribution
of product (if product is involved).
Check as many as apply:

Within 1 county/area.
Specify county/area:
Across multiple counties in the
same state. Specify areas:
Within 1 state. Specify state:
Across state lines

To complete this application, submit a
sample of product(s) and proposed use
of the 4-H Name and/or Emblem, or
submit graphic image(s) of the same.
List samples of products or exhibits
submitted here:
CSREES-01 (_______) Page 2