PRESIDENT’S VOLUNTEER SERVICE AWARDS
FORMS A, B, C, D, AND E
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 P.O. boxes are not accepted
City
State
Zip
Phone
Fax
Website
Is this a/an [Choice of: Independent Organization, Organization Headquarters, Chapter Location/Regional Office]
CONTACT PERSON FOR YOUR ORGANIZATION
First Name
Last Name
Street Address
City
State
Zip
Title
Phone
Please re-enter email
CEO/EXECUTIVE DIRECTOR
First Name
Middle Initial
Last Name
Date of Birth for Name Listed Above Used to verify identify during our clearance process
Type of Organization Used to verify identify during our clearance process
[Choice of: National Service Organization, Fraternity/Sorority, Nonprofit, Faith-Based, College/University, K-12, Government, Business, Other]
VOLUNTEER INFORMATION
Number of volunteer active with your organization annually
Approximately how many volunteers do you plan to recognize a year
Mission of Your Organization Briefly describe the mission of your organization
What audience do you serve?
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.
Education – Provide services that help children and youth achieve success and increase high school graduation.
Healthy Futures – Provide services such as access to healthcare, disease prevention and health promotion initiatives and healthy literacy.
Environmental Stewardship – Provide energy efficiency and other environmental conservation or restoration services within the communities.
Veterans and Military Families – 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.
Economic Opportunity – Provide services relation to economic opportunity for economically disadvantaged individuals within communities including financial literacy, housing assistance, job training and nutritional assistance.
Disaster Services – Build the capacity of national service network organizations to help prepare for, respond to, recover from and mitigate disasters and increase economic opportunity.
Other [Choice of: Adult Literacy & Education, Animal Support, Arts & Culture, Civic & Community, Faith Based Service, Family Services, Immigrant & Refugee Services, International Service, Justice & Legal, Senior Services, Sports & Recreation, Technology, Other]
If you have identified any one of the six focus areas above as primary services delivered through your services, may we contact you to learn more?
[Checkbox] Yes, PVSA may contact me about my focus area.
Mark the checkbox below if you would like to be included in a National Directory of President’s Volunteer Service Award participating 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
[Checkbox] Yes, please include me in a National Directory of President’s Volunteer Service Awards
OPT-IN PREFERENCES
Points of Light is a leading volunteer service organization and is the administrator of the President’s Volunteers Service Aawards program. As leading organizations in the industry, we have is aware of 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.
[Checkbox] Yes, I am interested in receiving emails about events and opportunities around national service (AmeriCorps, Senior Corps, Social Innovation Fund) and civic engagement.
[Checkbox] I am interested in being notified of PVSA-related items only.
[Checkbox] Please do not email me with any information unless it is administrative.
By checking the boxes below, you attest that the following statements are true and accurate:
[Checkbox] My organization is legally registered entity in the United States.
[Checkbox] The volunteers I intend to recognize with the President’s Volunteer Service Awards are United States citizens or are lawfully admitted permanent resident of the United States.
[Checkbox] All information contained in this application is true and accurate. The individuals listed do not impersonate a person or entity or otherwise misrepresent our affiliation with a person or entity.
[Checkbox] My volunteers participating with our program do not encourage or provide instructions for a criminal offense, violate the human rights of any individual, or would violate any local, state, or international law.
[Checkbox] I understand PVSA has adopted a policy of terminating participation in the PVSA, in appropriated circumstances as determined by PVSA’s sole discretion, of any participants or account holders.
[Checkbox] By checking this box, you confirm that you agree to our terms and conditions for the PVSA program
Form B. Leadership Organization Application
To begin your application, please enter the course completion code here:
ORGANIZATION
INFORMATION
Organization
Legal Name
Street Address P.O. boxes are not accepted
City
State
Zip
Phone
Fax
Website
Is this a/an [Choice of the following: Organization Headquarters, Chapter Location/Regional Office]
CONTACT PERSON FOR YOUR ORGANIZATION
First Name
Last Name
Street Address
City
State
Zip
Title
Phone
Please re-enter email
CEO/EXECUTIVE DIRECTOR
First Name
Middle Initial
Last Name
Date of Birth for Name Listed Above Used to verify identify during our clearance process
CFO
First Name
Middle Initial
Last Name
Date of Birth for Name Listed Above Used to verify identify during our clearance process
Type of Organization Used to verify identify during our clearance process
[Choice of: National Service Organization, Fraternity/Sorority, Nonprofit, Faith-Based, College/University, K-12, Government, Business, Other]
Are you a HandsOn Network Affiliate? [Choice of: Yes/No]
Mission of your Organization Briefly describe the mission of your organization
Describe your Organizational Structure Briefly describe your organizational structure in terms of local, state, or regional entities (i.e., chapter, affiliate, or regional offices), number of these entities and total number of volunteers reached
What Audience Do You Serve?
[Checkbox] I am committing to issue at least 1,000 President’s Volunteer Service Awards within a 12 month time period and will promote the award to all entities that constitute my network of offices/chapters.
[Checkbox] 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.
Education – Provide services that help children and youth achieve success and increase high school graduation.
Healthy Futures – Provide services such as access to healthcare, disease prevention and health promotion initiatives and healthy literacy.
Environmental Stewardship – Provide energy efficiency and other environmental conservation or restoration services within the communities.
Veterans and Military Families – 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.
Economic Opportunity – Provide services relation to economic opportunity for economically disadvantaged individuals within communities including financial literacy, housing assistance, job training and nutritional assistance.
Disaster Services – Build the capacity of national service network organizations to help prepare for, respond to, recover from and mitigate disasters and increase economic opportunity.
Other [Choice of: Adult Literacy & Education, Animal Support, Arts & Culture, Civic & Community, Faith Based Service, Family Services, Immigrant & Refugee Services, International Service, Justice & Legal, Senior Services, Sports & Recreation, Technology, Other]
If you have identified any one of the six focus areas above as primary services delivered through your services, may we contact you to learn more?
[Checkbox] Yes, PVSA may contact me about my focus area.
Mark the checkbox below if you would like to be included in a National Directory of President’s Volunteer Service Award participating 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
[Checkbox] Yes, please include me in a National Directory of President’s Volunteer Service Awards
OPT-IN PREFERENCES
Points of Light is a leading volunteer service organization and is the administrator of the Presidents Volunteers Service awards program. As leading organizations 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.
[Checkbox] Yes, I am interested in receiving emails about events and opportunities around national service (AmeriCorps, Senior Corps, Social Innovation Fund) and civic engagement.
[Checkbox] I am interested in being notified of PVSA-related items only.
[Checkbox] Please do not email me with any information unless it is administrative.
Form C. Volunteer Profile Application
NOTICE: 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
Birth Date
Street
City
State
Country
ZIP Code
Phone
Your Email Address
Verify Your Email Address
Password
Confirm 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 and up to 2 additional secondary focuses from the list.
Education – Provide services that help children and youth achieve success and increase high school graduation.
Healthy Futures – Provide services such as access to healthcare, disease prevention and health promotion initiatives and healthy literacy.
Environmental Stewardship – Provide energy efficiency and other environmental conservation or restoration services within the communities.
Veterans and Military Families – 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.
Economic Opportunity – Provide services relation to economic opportunity for economically disadvantaged individuals within communities including financial literacy, housing assistance, job training and nutritional assistance.
Disaster Services – Build the capacity of national service network organizations to help prepare for, respond to, recover from and mitigate disasters and increase economic opportunity.
Other [Choice of: Adult Literacy & Education, Animal Support, Arts & Culture, Civic & Community, Faith Based Service, Family Services, Immigrant & Refugee Services, International Service, Justice & Legal, Senior Services, Sports & Recreation, Technology, Other]
Gender [Choice of: Male, Female, Other] Optional
Ethnicity:
Are you of Latino or Hispanic origin or descent, such as Mexican, Puerto Rican, Cuban or some other Latin American background? [Choice of: Yes/No]
What is your race? [Choice of: American Indian or Alaskan Native, Asian, Black/African American, Native Hawaiian or Pacific Islander, White]
Highest Level of Education Completed [Choice of: Some High School, High School Graduate, Some College, Technical/Associate Degree, Undergraduate/College Degree, Graduate Degree, Other]
OPT-IN PREFERENCES
Points of Light is a leading volunteer service organization and are the administrator of the President’s Volunteers Service Award program for the Corporation for National and Community Service. 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.
[Checkbox] Yes, I am interested in receiving emails about events and opportunities around national service (AmeriCorps, Senior Corps, Social Innovation Fund) and civic engagement.
[Checkbox] I am interested in being notified of PVSA-related items only.
[Checkbox] Please do not email me with any information unless it is administrative.
Form D. Report Template for Hours Tracked Externally
INDIVIDUAL AWARD
First Name
Last Name
Age Group [Choice of: Kids (5-10), Teens (11-15), Young Adults (16-25), or Adults (26 and older)]
Hours Served Numbers only
Focus Area [Choice of: Education, Healthy Futures, Environmental Stewardship, Veterans and Military Families, Economic Opportunity, Disaster Services, or Other]
Print Focus Area Enter Yes or No
Year of Service Format: yyyy
Email Used to match to an existing PVSA volunteer account, if available. Please provide email address for honoree recognized. We do not sell or solicit at all.
GROUPS & FAMILIES
Group Name
Number of Members Integer numbers only
Group Type Enter: Family or Group
Hours Served Numbers only
Focus Area [Choice of: Education, Healthy Futures, Environmental Stewardship, Veterans and Military Families, Economic Opportunity, Disaster Services, or Other]
Print Focus Area Enter Yes or No
Year of Service Format: yyyy
Form E. Award Order Form
INDIVIDUALS
Full Name [Pre-populated from other forms]
Age Group [Pre-populated from other forms]
Hours Served [Pre-populated from other forms]
Hours Certified [Pre-populated from other forms]
Year [Pre-populated from other forms]
Focus Area [Choice of: Education, Healthy Futures, Environmental Stewardship, Veterans & Military Families, Economic Opportunity, Disaster Services, Other]
Print Focus Area [Checkbox]
GROUPS
Group Name [Pre-populated from other forms]
Members [Pre-populated from other forms]
Hours [Pre-populated from other forms]
Year [Pre-populated from other forms]
Focus Area [Choice of: Education, Healthy Futures, Environmental Stewardship, Veterans & Military Families, Economic Opportunity, Disaster Services, Other]
Print Focus Area [Checkbox]
LEGAL COMPLIANCE
[Checkbox] Check this box to affirm that the following statements are true and accurate
All volunteers I am requesting awards for are United States citizens or are lawfully admitted permanent residents of the United States.
These awards are issued for completed service hours only and are not contingent on any financials or philanthropic contribution.
I have read and am in compliance with all the terms and conditions that govern the PVSA program
I understand my responsibility when issuing these award to uphold the integrity of the office of the president of the United States and PVSA
SELECT AWARD PACKAGES
Name on Certificate [Pre-populated from other forms, editable]
Award/Package [Choice of: Complete Package Pin, Complete Package Coin, Complete Package Medal, Certificate Package, Lapel Pin Only, Coin Only, Medallion Only]
SELECT SHIPPING ADDRESS
[Choice of address pre-populated from account records or new address.]
Country
Street Address
Street Address 2
City
State
Zip Code
Phone
Requestor First Name
Requestor Middle Name
Requestor Last Name
Requestor Date of Birth
Organization Name
SELECT BILLING ADDRESS
[Choice of address pre-populated from account records or new address.]
Country
Street Address
Street Address 2
City
State
Zip Code
Phone
Email Address
SHIPPING OPTIONS
Requested Delivery Date
PROMOTION CODE
If you have a promotion or discount code, enter it below and click on “Apply Code.” Only valid codes will be accepted. One code per order.
Enter Code:
DELIVERY SPEED
[Checkbox] UPS Next Day Air Next business day delivery by 10:30 a.m., 12:00 noon, or end of day, depending on destination
[Checkbox] UPS 2nd Day Air Delivery by the end of the second business day. Some locations in Alaska and Hawaii require additional transit time
[Checkbox] UPS 3rd Day Select Delivery by the end of the third business day
[Checkbox] UPS Ground Day-definite delivery typically in one to five days
PAYMENT INFORMATION
Payment Method [Choice of Credit Card, Invoice me]
Name on the Card
Card Number
CVV
Expiration
Billing Zip Code
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Premo, Dave |
| File Modified | 0000-00-00 |
| File Created | 2021-01-14 |