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The applicant has personally appeared before me APPLICANT’S RECORD COUNSELOR’S RECORD

and demonstrated to my satisfaction that he has met


all requirements for the (please print):
Name ________________________________________ Applicant ___________________________________
________________________________________________
Merit Badge

________________________________________________ has given me his completed application for the o Troop


Name of Counselor
o Team Unit number: ____________________
________________________________________________ _____________________________________________
Address of Counselor
Merit Badge
o Post
________________________________________________
City ZIP Code
Completed on __________/_________/_________ by __________________________________________
________________________________________________ Merit Badge
Telephone number of Counselor

_____________________________________/_____/_____ _____________________________________________
Signature of Counselor Date Completed _________/_________/__________
Signature of counselor Date
Remarks:
Checked and recorded:
_____________________________________________
________________________________________________ Signature of unit leader
Date Initials
Certificate and badge presented: _____________________
Date

Applicant will turn in this portion to his unit NOTE TO BOY SCOUT, VARSITY SCOUT, OR It is suggested that the counselor keep this record
leader for record posting. EXPLORER: Retain this copy for your permanent for at least 1 year in case any question is raised
records. later in regard to this award.

The applicant has personally appeared before me APPLICANT’S RECORD COUNSELOR’S RECORD
and demonstrated to my satisfaction that he has met
all requirements for the (please print):
Name ________________________________________ Applicant ___________________________________
________________________________________________
Merit Badge

________________________________________________ has given me his completed application for the o Troop


Name of Counselor
o Team Unit number: ____________________
________________________________________________ _____________________________________________
Address of Counselor
Merit Badge
o Post
________________________________________________
City ZIP Code
Completed on __________/_________/_________ by __________________________________________
________________________________________________ Merit Badge
Telephone number of Counselor
_____________________________________________
_____________________________________/_____/_____ Date Completed _________/_________/__________
Signature of counselor Date Signature of Counselor
Remarks:
Checked and recorded:
_____________________________________________
________________________________________________ Signature of unit leader
Date Initials
Certificate and badge presented: _____________________
Date

Applicant will turn in this portion to his unit NOTE TO BOY SCOUT, VARSITY SCOUT, OR It is suggested that the counselor keep this record
leader for record posting. EXPLORER: Retain this copy for your permanent for at least 1 year in case any question is raised
records. later in regard to this award.

The applicant has personally appeared before me APPLICANT’S RECORD COUNSELOR’S RECORD
and demonstrated to my satisfaction that he has met
all requirements for the (please print):
Name ________________________________________ Applicant ___________________________________
________________________________________________
Merit Badge

________________________________________________ has given me his completed application for the o Troop


Name of Counselor
o Team Unit number: ____________________
________________________________________________ _____________________________________________
Address of Counselor
Merit Badge
o Post
________________________________________________
City ZIP Code
Completed on __________/_________/_________ by __________________________________________
________________________________________________ Merit Badge
Telephone number of Counselor

_____________________________________/_____/_____ _____________________________________________
Signature of Counselor Date Completed _________/_________/__________
Signature of counselor Date
Remarks:
Checked and recorded:
_____________________________________________
________________________________________________ Signature of unit leader
Date Initials
Certificate and badge presented: _____________________
Date

Applicant will turn in this portion to his unit NOTE TO BOY SCOUT, VARSITY SCOUT, OR It is suggested that the counselor keep this record
leader for record posting. EXPLORER: Retain this copy for your permanent for at least 1 year in case any question is raised
records. later in regard to this award.
APPLICATION FOR

Counselor
Information for Applicant

Initial
MERIT BADGE
• A merit badge application can be approved only by
a registered merit badge counselor.
Name______________________________________
• You must have a buddy with you (Scout buddy

Approval
Date of
system) at each meeting with the merit badge Address____________________________________
counselor. City________________________________________
• Turn in your approved application to your unit is a registered
leader. You will be awarded the merit badge em-
o Boy Scout o Varsity Scout o Explorer

Requirement
no and letter
blem and certificate at a suitable occasion.
of _______________________________ No._______
Troop, team, post, ship
Information for Counselor
District ______________________________________
• Merit badge applications must be signed in ad-

Requirement Date of Counselor


vance by the applicant’s unit leader.

Initial
Council______________________________________
• The Scout must have his buddy (Scout buddy
system) in attendance at all instructional sessions. and is qualified to begin working for merit
badge noted on the reverse side.

no and letter Approval


• You may not change any requirement, but you
may share your knowledge or experience that will
__________ ______________________
make the counseling more interesting and valu-
Date Signature of Unit Leader
able.
BOY SCOUTS OF AMERICA

7 30176 34124 8 No. 34124 1996 Printing

APPLICATION FOR
Counselor

Information for Applicant


Initial

MERIT BADGE
• A merit badge application can be approved only by
a registered merit badge counselor.
Name______________________________________
• You must have a buddy with you (Scout buddy
Approval
Date of

system) at each meeting with the merit badge Address____________________________________


counselor. City________________________________________
• Turn in your approved application to your unit is a registered
leader. You will be awarded the merit badge em-
o Boy Scout o Varsity Scout o Explorer
Requirement
no and letter

blem and certificate at a suitable occasion.


of _______________________________ No._______
Troop, team, post, ship
Information for Counselor
District ______________________________________
• Merit badge applications must be signed in ad-
Requirement Date of Counselor

vance by the applicant’s unit leader. Council______________________________________


Initial

• The Scout must have his buddy (Scout buddy


system) in attendance at all instructional sessions. and is qualified to begin working for merit
badge noted on the reverse side.
no and letter Approval

• You may not change any requirement, but you


may share your knowledge or experience that will __________ ______________________
make the counseling more interesting and valu- Date Signature of Unit Leader
able.
BOY SCOUTS OF AMERICA

7 30176 34124 8 No. 34124 1996 Printing

APPLICATION FOR
Counselor
Initial

Information for Applicant MERIT BADGE


• A merit badge application can be approved only by
a registered merit badge counselor. Name______________________________________
Approval
Date of

• You must have a buddy with you (Scout buddy Address____________________________________


system) at each meeting with the merit badge
counselor. City________________________________________

• Turn in your approved application to your unit is a registered


leader. You will be awarded the merit badge em- o Boy Scout o Varsity Scout o Explorer
Requirement
no and letter

blem and certificate at a suitable occasion.


of _______________________________ No._______
Troop, team, post, ship
Information for Counselor District ______________________________________
Requirement Date of Counselor

• Merit badge applications must be signed in ad-


Initial

vance by the applicant’s unit leader. Council______________________________________


• The Scout must have his buddy (Scout buddy and is qualified to begin working for merit
system) in attendance at all instructional sessions.
no and letter Approval

badge noted on the reverse side.


• You may not change any requirement, but you
may share your knowledge or experience that will __________ ______________________
make the counseling more interesting and valu- Date Signature of Unit Leader
able.
BOY SCOUTS OF AMERICA

7 30176 34124 8 No. 34124 1996 Printing