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NACURH, Inc. Four Year Service Pin Application Name:

School:

Region:

E-mail:

Will you be attending the upcoming NACURH Annual Conference (Circle one):

Yes

No

Please answer the following questions. If there is not sufficient space, please attach additional sheets. 1. List your four years of service in the residence hall(s), Residence Hall Association, National Residence Hall Honorary or other residence hall organization(s). Please indicate the year (1st, 2nd, 3rd and 4th) in which you participated in the activity. NOTE: There must be at least one activity per year. ACTIVITY

YEAR

2. List which NACURH-affiliated regional and national conferences you have attended, the year and where they were held. NOTE: There must be at least one NACURH Annual Conference and state/subregional conferences will not count toward this requirement. CONFERENCE

3.

YEAR

Are your four years of residence hall involvement at the same school? (Circle one)

LOCATION

Yes

No

I hereby certify that all of the information provided here is true and correct. I understand that without proper verification from my school’s NCC, Advisor, and Regional Director, I forfeit my right to the Four Year Service Award. I understand that this application must be turned in to the Regional Director by April 1. Signature of Applicant

Date

______________________________________________________________________________________________________ We, as the NCC, residence hall government Advisor, and Regional Director, hereby certify that all of the information provided is true and correct to the best of our knowledge, and certify that the above named applicant is eligible for the Four Year Service Award. National Communications Coordinator

Date

Residence Hall Association Advisor

Date

Regional Director

Date

________________________________________________________________________

______________________

National Chair

Date