American Statistical Association
Award for Outstanding Chapter Service Form

Please complete the form below no later than 4:00 PM (EDT) on April 22. Forms received after this date are not guaranteed to be included in the Presidential Address program booklet. Should you have any questions, please contact Rick Peterson at

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Recipient Information
Name of Recipient
City State Zip Code
Certificate Information
Name of Chapter
Name of Award
Wording on Certificate
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Note: All certificates will be signed by the Council of Chapters Governing Board Chair and the ASA President. Certificates will not be placed in holder to allow others the chance to sign if desired.
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