Form 1 President's Volunteer Service Award Application Form

PRESIDENT’S VOLUNTEER SERVICE AWARDS

FORMS A, B, C, D, E AND F

President's Volunteer Service Awards, Part A, B, C, D, and E

PUBLIC BURDEN STATEMENT: Public reporting burden for this collection of information is estimated to average 20 minutes per submission, including reviewing instructions, gathering and maintaining 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, Attn: Amy Borgstrom, 1201 New York Avenue, NW, 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 on page 1 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 information requested on the President's Volunteer Service Awards form is collected pursuant to 42 U.S.C 12592 and 12615 of the National and Community Service Act of 1990 as amended, and 42 U.S.C. 4953 of the Domestic Volunteer Service Act of 1973 as amended. Purposes and Uses - The information requested is collected for the purposes of reviewing applications to receive the President's Volunteer Service Award. Routine Uses - Routine uses may include disclosure of the information to federal, state, or local agencies pursuant to lawfully authorized requests. In some programs, the information may also be provided to federal, state, and local law enforcement agencies to determine the existence of any prior criminal convictions. The information may also be provided to appropriate federal agencies and Department contractors that have a need to know the information for the purpose of assisting the Department’s efforts to respond to a suspected or confirmed breach of the security or confidentiality or information maintained in this system of records, and the information disclosed is relevant and unnecessary for the assistance. The information will not otherwise be disclosed to entities outside of the Corporation for National and Community Service without prior written permission. Effects of Nondisclosure - The information requested is mandatory in order to receive benefits.

OMB Control Number 3045-0086

Expiration Date tbd

Form A Certifying Organization Application

To begin your application, please enter the course completion code here: ________

ORGANIZATION INFORMATION

Organization Legal Name

Street Address (No PO boxes accepted)

City

State

Zip

Phone

Fax

Website

Is this (Choice of the following: Independent Organization, Organization headquarters, Chapter Location/regional office)

CEO/Executive Director/President of Organization

Date of birth

Contact person for your organization

First Name

Last Name

Title

Phone

Email

Email

Check Box

for all: Please check the type organization. (Please check all that apply.)

Business

Community Program

Fraternity/Sorority

Human Services

National Service Organization

School

Volunteer Center

College/University

Faith Based

Government

Labor Union

Nonprofit

Service Club

Youth Development Organization

Other (please specify)

Number of volunteers active with your organization annually_______

How many volunteers do you plan to recognize a year? ____________

Briefly describe the mission of your organization.

Comment

Box:

What audience do you serve?

Comment

Box:

Please select the primary focus area of your services from the list below. You must indicate your primary focus and may have up to two additional secondary focus areas from the list below.

Check Box: Education – Provide services that help children and youth achieve success and increase high school graduation.

Check Box: Healthy futures – Provide services such as access to healthcare, disease prevention and health promotion initiatives and healthy literacy.

Check Box: Environmental Stewardship – Provide energy-efficiencies and other environmental conservation or restoration services within the communities.

Check Box: Veterans and Military – Provide services to veterans, Members of the Armed forces who are in the active duty, and family members of deployed military personnel and. or engaged veterans in service.

Check Box: Economic opportunity – Provide services relation to economic opportunity for reconloical disadvantaged individuals within communities including financial literacy, housing assistance job training and nutritional assistance.

Check Box: Disaster Services – build the capacity of national service network organizations to help their states and local entities, prepare, respond recover and mitigate disasters and increase community resiliency.

Check Box: Other focus areas___________________________________________

If you have identified any one of the six focus areas above as a primary services delivered through your services, may we contact you to learn more? Y N

Check Box: Check here if you would you like to be included in a National Directory of President’s Volunteer Service Award’s participating Certifying Organizations. Participation in the directory involves:

• Allowing Points of Light to reference or send individuals looking to provide service in your designated category to you.

• Grants permission for individuals to reach out to your organization if they are interested in supporting your organization with service.

• The National directory will sit on the PVSA site for organic traffic to see.

Opt in preferences

Points of Light is a leading volunteer service organization and is the administrator of the Presidents Volunteers Service awards program. As a leading organization in the industry, we have our finger on events, activities and thought leadership opportunities you may be interested in. Please check the box below for the appropriate information you would be interested in receiving.

Check box: Yes, I am interested in receiving the Presidents Volunteer Service Award Newsletter.

Check box: Yes, I am interested in receiving emails about events and opportunities around National Service (AmeriCorps, Senior Corps, Social Innovation Fund) and civic engagement.

Check box: I am interested in being notified of PVSA related items only.

Check box: Please do not email me with any information unless it is administrative only.

Honor code paragraph –

Check Box: By checking this box, you attest that the following statements are true and accurate:

1. My organization is a legally registered entity in the United States

2. The volunteers I intend to recognize with the president’s Volunteer Service Award are United States citizens or are lawfully admitted permanent residents of the United States.

3. All information contained in this application is true and accurate. The individuals identified to receive the award are verified as actual volunteers affiliated with our organization.

4. Volunteer participation with our program does not encourage or condone any illegal activity, violate the human rights of any individual, or would violate any local, state or international law.

5. I understand PVSA has adopted a policy of terminating, at the sole discretion of the administrators of the PVSA, participants or account holders found to violate the rules of the program.

Check Box: By checking this box, you confirm that you agree to our Terms and conditions for the PVSA program.

Form B Order Certifying

Questions for individual award:

First name

Last name

Age Group (options are Kid, Young Adult, or Adult)

Hours served

Lifetime Award? (yes or no)

Award period ending on (date)

Date of birth

Focus Area

Number of hours by focus area

Ethnicity/Race

Description of service

Questions for group award:

Group name

Number of members

Group type (options are Family or Group)

Hours served

Award period ending on (date)

Focus area(s)

Description of service

Form C Volunteer Profile Application

If you are 14 years of age or under you must have parent/guardian consent to set up your profile.

First Name:

Middle Name:

Last Name:

Date of Birth: Month, Day, Year

Check Box: I verify that the email address I am providing is my parents/guardians correct email address for approval of my participation with the PVSA program

Parents email address

Verify parents email address.

Street Address:

City

State

Zip

Phone

Email address

Verify email address

Username

Verify user name

Create a password

Verify Password

Please share with us your service focus area of interest. Below you will find a list of key focus areas to the nation. Please let us know if your interest falls within any of these areas by indicating your primary focus with a 1 and you can add up to 2 additional secondary focuses from the list by marking the 2 & 3.

Check Box: Education – Provide services that help children and youth achieve success and increase high school graduation.

Check Box: Healthy futures – Provide services such as access to healthcare, disease prevention and health promotion initiatives and healthy literacy.

Check Box: Environmental Stewardship – Provide energy-efficiencies and other environmental conservation or restoration services within the communities.

Check Box: Veterans and Military – Provide services to veterans, Members of the Armed forces who are in the active duty, and family members of deployed military personnel and. or engaged veterans in service.

Check Box: Economic opportunity – Provide services relation to economic opportunity for reconloical disadvantaged individuals within communities including financial literacy, housing assistance job training and nutritional assistance.

Check Box: Disaster Services – build the capacity of national service network organizations to help their states and local entities, prepare, respond recover and mitigate disasters and increase community resiliency.

Check Box: Other focus areas___________________________________________

Gender (optional): Male, Female

Ethnicity (optional):

Are you of Latino or Hispanic origin or descent, such as Mexican, Puerto Rican, Cuban or some other Latin American Background

• Yes, Hispanic or Latino

• No, Not Hispanic or Latino

Race: What is your race? Are you (choice of the following: Caucasian, Black/African America, Asian, American Indian, Native Alaskan, Hawaiian or other Pacific Islander? You may select more than one race (Select all that you feel apply)

Education Level:

Some High School, High school Graduate, Some College, Technical/Associate degree, 4 year college degree, Graduate degree, Unknown, Other

Opt in preferences

Points of Light is a leading volunteer service organization and is the administrator of the Presidents Volunteers Service awards program. As a leading organization in the industry, we have our finger on events, activities and thought leadership opportunities you may be interested in. Please check the box below for the appropriate information you would be interested in receiving.

Check box: Yes, I am interested in receiving the Presidents Volunteer Service Award Newsletter.

Check box: Yes, I am interested in receiving emails about events and opportunities around National Service (AmeriCorps, Senior Corps, Social Innovation Fund) and civic engagement.

Check box: I am interested in being notified of PVSA related items only.

Check box: Please do not email me with any information unless it is administrative only.

Form D Leadership Organization Application

ORGANIZATION INFORMATION

Organization Legal Name

Street Address- must be headquarters loc

City

State

Zip

Phone

Fax

Website

Is this (X)Organization headquarters (X) Chapter Location/regional office

CEO/Executive Director/President of Organization

Date of Birth (used to verify identity during our clearance process)

CFO

Date of Birth (used to verify identity during our clearance process)

Contact person for your organization/PVSA program

First Name

Last Name

Street Address

City

State

Zip

Title

Phone

Email

Email

Please check the type organization. (Please check all that apply.)

Business

Community Program

Fraternity/Sorority

Human Services

National Service Organization

School

Volunteer Center

College/University

Faith Based

Government

Labor Union

Nonprofit

Service Club

Youth Development Organization

Other (please specify)

Briefly describe the mission of your organization.

Briefly describe your organizational structure in terms of local, state or regional entities (i.e. chapter, Affiliate or regional offices), numbers of these entities and total number of volunteers reached.

(Example 50 state offices presiding over 1,000 local chapters, each with about 50 volunteers.

What audience do you serve?

Check Box: I am committing to issue at least 2,500 President Volunteer Service Awards in the next two years and will promote the AWARD to all entities that constitute my network of offices/chapters.

Check Box: Please check here if you would like to receive creative assets to support your marketing and promotion efforts for the program.

Please select the primary focus area of your services from the list below. You must indicate your primary focus and may have up to two additional secondary focus areas from the list below. Please list 1-3 in order of priority.

Check Box: Education – Provide services that help children and youth achieve success and increase high school graduation.

Check Box: Healthy futures – Provide services such as access to healthcare, disease prevention and health promotion initiatives and healthy literacy

Check Box: Environmental Stewardship – Provide energy-efficiencies and other environmental conservation or restoration services within the communities.

Check Box: Veterans and Military – Provide services to veterans, Members of the Armed forces who are in the active duty, and family members of deployed military personnel and. or engaged veterans in service.

Check Box: Economic opportunity – Provide services related to economic opportunity for reconloical disadvantaged individuals within communities including financial literacy, housing assistance job training and nutritional assistance.

Check Box: Disaster Services – build the capacity of national service network organizations to help their states and local entities, prepare, respond recover and mitigate disasters and increase community resiliency.

Check Box Other focus areas_____________________________________________

If you have identified any one of the six focus areas above as a primary services delivered through your services, may we contact you to learn more? Y N

Check Box: Check here if you would you like to be included in a National Directory of President’s Volunteer Service Award’s participating Certifying Organizations. Participation in the directory involves:

• Allowing Points of Light to reference or send individuals looking to provide service in your designated category to you.

• Grants permission for individuals to reach out to your organization if they are interested in supporting your organization with service.

• The National directory will sit on the PVSA site for organic traffic to see.

Opt in preferences

Points of Light is a leading volunteer service organization and is the administrator of the Presidents Volunteers Service awards program. As a leading organization in the industry, we have our finger on events, activities and thought leadership opportunities you may be interested in. Please check the box below for the appropriate information you would be interested in receiving.

Check box: Yes, I am interested in receiving the Presidents Volunteer Service Award Newsletter.

Check box: Yes, I am interested in receiving emails about events and opportunities around National Service (AmeriCorps, Senior Corps, Social Innovation Fund) and civic engagement.

Check box: I am interested in being notified of PVSA related items only.

Check box: Please do not email me with any information unless it is administrative only.

Honor code paragraph –

Check Box: By checking this box, you attest that the following statements are true and accurate:

6. My organization is a legally registered entity in the United States

7. The volunteers I intend to recognize with the president’s Volunteer Service Award are United States citizens or are lawfully admitted permanent residents of the United States.

8. All information contained in this application is true and accurate. The individuals identified to receive the award are verified as actual volunteers affiliated with our organization.

9. Volunteer participation with our program does not encourage or condone any illegal activity, violate the human rights of any individual, or would violate any local, state or international law.

10. I understand PVSA has adopted a policy of terminating, at the sole discretion of the administrators of the PVSA, participants or account holders found to violate the rules of the program.

Check Box: By checking this box, you confirm that you agree to our Terms and conditions for the PVSA program.

Form E Award Order Form

(most fields will be pre-populated from other forms)

Requester name and date of birth -

Agreement check box to confirm compliance with Terms & Agreements and PVSA honor code.

Email address.

Selection of Award level

Provide contact phone number

Provide Shipping address

Provide Credit Card number and CVV number

Provide Billing Address and zip code

President's Volunteer Service Award
Request for Refund
Order Date:				Name of Certified Organization:
Order Number:				Certified Organization Number:
Total Order Cost:				Contact Name:
Requested Refund:				Phone Number:
Email Address:
"Refund to" Information:				Reason for refund request:
Charged for items not received				*Name on Card:
Card Number:				Paid for express/rush delivery
and items where not rushed				Exp. Date:
Card type:				Items did not match order form
Card CVV Code:				Duplicate Charge on Bill
Other:				Billing address:
*Credit Card from original transaction
Additional Comments:
Please attach copies of all documentation that applies:
Canceled checks, copy of original order (if not placed online), copy of past relevant correspondence with PVSA team, credit card statement.
Complete Requests, including this form and all supporting documents, should be sent as one package either via email or mail. Please DO NOT send as separate pieces, this could delay processing.
Please return this form to either:
Email:				[email protected]
Address:				Presidents Volunteer Service Awards
co: Points of Light Institute
600 Means Street NW Suite 210
Atlanta, GA 30318
For PVSA Office Use Only:
TOTAL CHARGE	REFUND DATE	REFUND AMOUNT	METHOD OF REPAYMNET		APP/DENY DATE	NOTE	DECISION LETTER DATE
Please note:
Completion of this form does not guarantee your requested refund. President's Volunteer Service Awards Team will process your request and determine proper action within 10-20 days of receipt of request at which time you will be notified of the results of your request. Actual processing of refunds will take longer. Thank you for your patience.