Request for a Certificate form

This form is being completed for

2025 CTA Member-In-Politics Award Program in Honor of Ted Bass

2025 CTA Chapter-In-Politics Award Program in Honor of Joyce Fadem

This form is to be completed by the Chapter President or Service Center Council chairperson along with the nomination form.

To be presented to

CTA Chapter Name(Required)

To be presented to

Other

Service Center Council

Date scheduled for presentation

Name of Service Center Council Chairperson(Required)

Certificate to be sent to

Address(Required)

Home Phone

Cell Phone

Email(Required)

Enter Email Confirm Email

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