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Certificate Request Form

Use this form to request a Certificate of Service for individuals or organizations starting at 50 Years You may request multiple names for each service year they must be the same organization.

Indicates Required Field

Date opened

10/28/2026 2121

Type of Certificate Requested Required

Individual Organization

Name of Requester Required

Requester Email

Requestoer Phone #

Name of Recipent Required

Organization Required

Year of Service Required

Date to be presented Required

Presentation Details

Would you like a NNYVFA Officer to present the Certificate ?

Yes No

Place and Address of Presentation

Date and Time of Presentation

Special Notes

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