RHASS Long Service Award
APPLICATION CONTACT
Name of individual who is completing this form on behalf of the award nominee
*
Prefix
First Name
Last Name
Email Address (this shall be used to inform you of the application status and delivery of award)
*
example@example.com
AWARD NOMINEE
Please provide the following information of the individual who shall be receiving the award
Nominee's Name
*
Prefix
First Names
Last Name
Nominee's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Nominee's Date of Birth
*
-
Month
-
Day
Year
Date
Nominee's Email Address
*
example@example.com
Nominee's Phone Number
*
Please enter a valid phone number.
Has the nominee previously received a RHASS Long Service Award?
*
Yes
No
If yes to the above, please select which award they received
*
30 Year
40 Year
N/A
EMPLOYER
Please provide the following information of the nominee's employer
Name of Employer (company/farm name)
*
Address of Employer (primary address, if have more than one location)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer Companies House Number
EMPLOYMENT
Please provide the following information of the nominee's employment
Nominee's Job Title
*
A brief description of their duties
*
Address of where nominee carries out their duties, if different to employer's primary address provided in Employer section
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Start Date of Employment
*
-
Month
-
Day
Year
Date
Current Status of Employment
*
Currently work with employer
Employment has ended
If box ticked "Employment has ended", please provide their employment end date
-
Month
-
Day
Year
Date
DECLARATION OF EMPLOYER
Please note that the employer must be a current member of RHASS in order for the award to be issued. By completing this section of the form, the employer to the best of their knowledge confirms that this is a true statement and that they support the application.
Name of Employer (owner of company/farm, or supervisor)
*
Prefix
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email Address Held on RHASS Member Account
*
example@example.com
RHASS Membership Number
*
DECLARATION OF RHASS MEMBER
Please note that the seconder of this application must be a current member of RHASS in order for the award to be issued. The seconder can be a colleague of the nominee or an individual, who declares that the nominee is personally known to them, that the applicant’s statement of farm service is to the best of the member’s knowledge is correct, and that the member considers the nominee to be a suitable person to receive the RHASS Long Service Award.
Name of Seconder
*
Prefix
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email Address Held on RHASS Member Account
*
example@example.com
RHASS Membership Number
*
PRESENTATION OF AWARD
Please note that it is the responsibility of the employer to arrange presentation. Where possible, a local RHASS director shall be in attendance to present the award.
Please select the preferred presentation method
*
Local agricultural society or body
Employer
Other
If you have selected "Local agricultural society or body", please provide the name of the Society, the name of their contact, email address, and telephone number
If you have selected "Other", please provide further information
Date of Presentation (please note that applications take 8 weeks to process)
*
DELIVERY OF AWARD
Please provide the following information of where the award is to be issued for presentation. Please note that for delivery of the award a signature may be required. You shall be notified when the award has been issued for delivery.
Who should the parcel be addressed to
*
Prefix
First Name
Last Name
Address of where the parcel should be issued to
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PAYMENT
My Products
*
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RHASS Long Service Awards
Long Service Award
£
95.00
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