...Return to 4H Name & Emblem Home OMB Approved No. 0524-0034
Expires 7/31/2012
UNITED STATES DEPARTMENT OF AGRICULTURE
NATIONAL INSTITUTE OF FOOD AND AGRICULTURE
WASHINGTON, DC 20250

APPLICATION FOR AUTHORIZATION TO USE THE 4-H NAME AND/OR EMBLEM
(Under provisions of 18 U.S.C. 707 and 7 CFR Part 8)

In certain situations, County or State Cooperative Extension Service/Land-Grant Institution authorization is required. When using a vendor, the vendor needs to seek authorization to use the 4-H Name and/or Emblem at the appropriate level. Duly authorized 4-H Clubs and County and State Cooperative Extension Services are among those authorized to use the 4-H Name & Emblem for their own educational or informational purposes, so long as they are consistent with federal legislation and regulations regarding the 4-H Name and/or Emblem.

Plan for sale OR distribution of product
(This includes both production
and distribution location)

Check only one:
Within one county/area only.
Within one state only.
Across state lines

Per regulations, NIFA reserves the right to review and revoke any authorization or permission for use of the 4-H Name and/or Emblem at any time.
_________________________________________________________________________________________________________________
*Name of Individual, Partnership, Corporation, or Association:
*Name of Authorized Representative:
*Title of Authorized Representative:
*Organizational Address:
Street Address
City
State Zip Code
*Telephone Number (include area code):
Fax Number (include area code):
*E-mail address:
Web Site:
_________________________________________________________________________________________________________________

*Type of Request:
*Proposed use of the 4-H Name and/or
Emblem (be specific):
*Length of time authorization requested:
_________________________________________________________________________________________________________________


*To complete this application, submit a sample of product(s) and proposed use of the 4-H Name and/or Emblem, or submit graphic image(s) of the same. (if you would like to upload multiple images please upload a zipped folder of all of the samples.)




*List here samples of products or exhibits submitted:
_________________________________________________________________________________________________________________

If authorization is granted, the applicant will accept the authorization with the understanding that:

a. The 4-H Name and/or Emblem will be used only as specified in the application and/or written authorization;

b. Authorization does not grant the applicant the exclusive right to the 4-H Name and/or Emblem for this or any other purpose;

c. The National Institute of Food and Agriculture may grant similar authorizations to competing organizations; and

d. This authorization is revocable at the discretion of the Director, National Institute of Food and Agriculture, or their designee, at any time after written notice.

By signing this form, the applicant acknowledges the federal legislation and regulations concerning use of the 4-H Name and/or Emblem. Agreement is hereby made that, if authorization is granted, the applicant will abide by all of the regulations therein.

(Name of Applicant) (Signature of Applicant)
(Title) (Date)

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0524-0034. The time required to complete this information collection is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.