NEBRASKA 4-H Annual Achievement

Application for Award and Recognition

Custer County 4-H P.O. BOX 161; 104 Maple Street

Thedford, NE 69166

Due January 1 5, 2019

Nebraska 4-H Annual Achievement Application for Awards and Recognition

This is a fillable form.

Please check the opportunities for which you are applying. You may check more than one:

Place an "X�''for areas you are '

Award Appli"c�tion for:,,; ,·., .·.· ';.' . . ,:·., ' , .·• ,. .

applying for ..

X

X

Name:

(First Middle Last)

Present Address:

City:

State:

Zip:

County (enrolled in 4-H):

Home Phone:

Cell Phone:

Email Address:

Date of Birth:

(MM/DD/YEAR)

Current Age:

Certification Statement

County Awards and Scholarships

State Level Awards and Scholarships

National 4-H Conference

National 4-H Congress

Other:

(please explain)

About Me

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By inserting initials below, I certify that the information in this application is accurate and complete.

Applicant's signature (typed initials):

HJP

Date:

12/29/18

Parent/Guardian's Signature (typed initials)

WP and JMP

Date:

12/29/18

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