Emerald Clover Nomination Form Nominee’s name*County of 4-H membership*Years of 4-H membership*to*(Note: Three years of documented Michigan 4-H membership is required in order for nominee to be considered.) Nominee’s most recent profession*Nominee’s current mailing address: (Note: This is required in order for a nominee to be considered. Nominees must be living and we must be able to contact them if they are chosen to receive this honor.) Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email* PhoneEvidence of professional/business achievement and success1. Leader in their professional field and/or evidence of academic leadership and success in their area of professional or business study if nominee is a college student or young professional.*(5 points)2. Innovation in their professional field.*(5 points)3. Local, state or national leadership, elected position or professional accomplishments recognized by others.*(5 points)Evidence of community service/philanthropy leadership4. Leader, chair, head of a major community service or philanthropic initiative.*(5 points)5. Donor or contributor whose gifts have made a recognized and significant impact on a community.*(5 points)6. City, county, state, national awards and honors for community service and/or philanthropy.*(5 points)Evidence of leadership in community, state and national affairs7. Community service, civic engagement and/or philanthropic impact that improves the way people in your local community or within Michigan lives.*(5 points)8. Community service, civic engagement and/or philanthropic impact that improves the way Americans live, regardless of who they are or where they reside.*(5 points)Evidence of leadership or achievement as a 4-H member/volunteer9. Success as a 4-H member:*List awards, recognition, leadership and achievements: (5 points)10. Evidence of success as a teen or adult 4-H volunteer:*List awards, recognition, leadership and achievements. (5 points)Who might also be contacted to share information about why this person should receive this recognition?Peer or Colleague*PhoneOtherPhoneNominated byNominator PhoneNominator Email* Mailing AddressThis information is requested so that we may provide notify you on the outcome of your nomination. Thank you.