Annual Request for Official Approval of a 4-H Unit, Certification of Nondiscrimination, and Permission to use 4-H Name and Emblem	AFFACT-662 10-16-2014
Name of Group	EIN Number:
Type of Group: (4 – H Club, 4 – H Special Interest Group, county 4 – H Leader’s Council, etc.)
Purpose of Group
This is to certify that the above named 4-H Unit is open to all eligible persons regardless of race, color, sex, gender identity, sexual orientation, national origin, religion, age, disability, marital or veteran status, genetic information, or any other legally protected status, and is an Affirmative Action/Equal Opportunity Employer. This is to certify that the above named 4-H unit is not a single family group.
Volunteer leader or other person in charge of 4 – H Unit (print name)
Signature	Date	County
E-Mail:	Phone #:
Address:
City:	State:	Zip:
Official Approval for 4-H Unit
On the basis of the above purpose(s), the
Is authorized to use the 4-H name and emblem in connection with its program and activities and is considered an official 4-H unit of the Cooperative Extension Service.
County Extension Agent – Staff chair
(Print name)
County Extension Agent – Staff chair
(Signature)
Date	Enter County