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GACP State Certification Service Award Request
Agency Name
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Applicant Name
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CEO Attestation
As CEO of the agency, I respectfully request consideration by the State Certification Committee for the following award and hereby certify that the information provided is accurate to the best of my knowledge and belief.
TO CERTIFY THIS SUBMISSION IS TRUE AND ACCURATE, PLEASE ENTER YOUR FULL NAME IN THIS BOX FOR ELECTRONIC SIGNATURE AND CLICK THE RADIO BUTTON BESIDE IT.
Agency CEO signature (or designee)
Click below to sign
Sign Name
Which award are you submitting documentation on?
MERITORIOUS AWARD - SILVER
The agency has successfully maintained its certification status for ten (10) continuous years. Documentation is required.
MERITORIOUS AWARD - GOLD
The agency has successfully maintained its certification status for twenty (20) continuous years. Documentation is required.
DISTINGUISHED AWARD
The agency has successfully maintained its certification status for thirty (30) continuous years. Documentation is required.
Select Award
Silver Meritorious Award - (10 Consecutive Years)
Gold Meritorious Award (20 Consecutive Years)
Distinguished Award - (30 Consecutive Years)
Upload Documentation (PDF or Word Document accepted)
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