B Individual certification Form

PRESIDENT'S VOLUNTEER SERVICE AWARDS FORM B
INDIVIDUAL AWARD CERTIFICATION FORM
A separate form should be completed for each intended recipient of the President's
Volunteer Service Award. Please type or print using blue or black ink. Photocopy
this form as needed. The Award Order Form and payment MUST accompany this form.
Please fax completed forms to 1-202-729-8033.

Individual Information
NAME
STREET ADDRESS
CITY
PHONE (
)
Name preferred on certificate

ZIP

STATE
EMAIL

Volunteer Information
How many hours did the nominee complete during the 12-month period? __________
Was the nominee 14 years or younger at the completion of the hours? _____yes _____no
Was the nominee 15 to 25 years old at the completion of the hours? _____yes _____no
Has the nominee completed over 4000 hours of service over his/her lifetime? _____yes _____no
Where did the nominee perform the majority of their volunteer service? _____________________ U.S. state or country

Service Classification (Check the box in which most of the volunteer activity took place.)
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.
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.

Tell us more about the award recipient's service. (35 words or fewer) (OPTIONAL)

Demographic Information (this section is optional)
Gender
Female
Male
Age
_____5-14 _____15-25 _____26-35 _____36-49

_____50+

Ethnicity: Hispanic or Latino? _____ yes _____ no
Race Please mark one or more
Alaska Native/ American Indian
Asian
Education (Highest level completed)

Black / African American
Native Hawaiian or Pacific Islander

White

K-8

High School or GED

Undergraduate Degree

9-11

Some College

Graduate/Professional Degree

I hereby certify that my organization has verified that each individual or group specified on this form has met the respective
criteria necessary to earn the President's Volunteer Service Award and completed the volunteer activities in at least one of the
four Volunteer Service Action Priorities.

Signature
Name of organization
See reverse for Public Burden Statement and Privacy Act Notice.

DATE

OMB Control #: 3045-0086
Expiration Date: 02/28/2007

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 B (Individual Certification Form)
All President’s Volunteer Service Awards must be verified and issued through institutions which we
call Certifying Organizations (CO). If the nominee is an individual, family, or group who is seeking
the PVSA and are associated with any organization such as a faith-based institution, school, higher
education, nonprofit and community based organization, business, labor union, civic or service club,
membership and trade association, and federal, state or local government agency, please ask for one
of these to become a CO and verify your service.
There is a nominal charge for the recognition packet. Some organizations may cover the cost of the
packet. If the CO is unable to cover this cost, it is appropriate for the individual volunteer, if asked,
to help cover the cost.
To earn an award, individuals, families and groups must keep a record of volunteer activities and
hours served. This record of service may be kept as a diary or calendar or tracked online with the
USA Freedom Corps Record of Service available on the President’s Volunteer Service Award site at
www.presidentialserviceawards.gov. An individual between the ages of 5 and 14, must complete a
minimum of 50 service hours during a 12-month period. An individual aged 15 and older, must
complete a minimum of 100 service hours during a 12-month period.
Individual Information:
Please fill out the individual information for each recipient, giving full address including city, state,
zip and phone number.
Volunteer Information: Please answer all questions.
How many hours did the awardee complete during the 12-month period? Please fill in number of
hours. The 12-month period does not depend on a calendar year, school year, or any other time
period other than the 12-month period preceding the application for the PVSA.
Has the nominee completed over 4000 hours of service over his/her lifetime? If so this individual has
earned the President’s Call to Service Award. During his 2002 State of the Union address, President
George W. Bush called upon every American to get involved in strengthening America's
communities and sharing America's compassion around the world. He called on each of us to
dedicate at least two years, or 4000 hours, over the course of our lives to the service of others.
Where did the individual perform the majority of their volunteer service? Please fill in the blank
with the location whether a U.S. state or other country, where the volunteer performed the majority
of service. Service can be in many locations, so please just indicate where the majority of service
took place.
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.
Optional Information:
Age: Please check appropriate age of individual at the completion of hours.
Race: Please mark all that apply.
Ethnicity: Does the individual consider himself or herself as Hispanic or Latino? Yes or no
Education: Please fill in the blank for the highest level completed.