Michigan 4-H Foundation » 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*

Phone

Evidence of professional/business achievement and success

1. 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 leadership

4. 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 affairs

7. 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/volunteer

9. 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*

Phone

Other

Phone

Nominated by

Nominator Phone

Nominator Email*

Mailing Address

This information is requested so that we may provide notify you on the outcome of your nomination. Thank you.

CAPTCHA