MAE4-HYW
Distinguished Service & Achievement Award Nomination Form
 

Nomination For: (check one)

Achievement in Service Award (ASA) _____ Distinguished Service Award (DSA) _____

 

Name of Nominee: ________________________________________

Title:____________________________________________________

Work Address: ___________________________________________

____________________________________________

Work Phone: _____________________________________________

SCORECARD (To be completed by committee)

Points Possible

Score
A. Professional Attitude                                        15 _____
-Work with professional association
- Extension committee work and responsibilities
B. Professional Improvement                              15 _____
- Advance formal education
- Supplemental Training (attendance at National Meeting can be counted)
C. Professional Accomplishments                   50 _____
- Size and depth of program
- Program improvements
- Program innovations
D. Personal/Community                                        15 _____
- Personal attitudes and interests
E. Special Honors                                                   5 _____
- Professional honors
- Community honors

Total Possible    100

 _____

 Please write a brief summary of program accomplishments (50 words or less):

 

 

 

 

 

 

 

Submitted By:

Title: