Form H: Governor Nominee Data Form November 2009
District Governor Candidate : Please complete and sign this form have your club secretary sign it and submitit to the district nominating commitee
Governor Year
______________
District
______________
Zone
_____________
Title(eg. : Mr./Ms./Mrs/Dr./Rev.)
____________________________
Suffix(eg. : Jr./Sr./III)
___________________________
Family Name
___________________________
First Name
___________________________
Middle Name
_____________
Call name as it should appear on your badge
____________________________________________
Male
Female
Single
Married
Widowed
Divorerd
City, Country, and, year of birth
___________________________________________________________________
Member, Rotary Club of
_______________________________________________________________________________________
(official name of club, including country)
RI membershp ID number
_____________________________
Year you first joined Rotary
_______________________________
Current(or former, if retired)classification
________________________
Current(or former, if retired)firm and position
________________________
if retired year of retirement
_____________________
Per RI By laws 15.070.3, a qualified Rotarian must have served a full term as club president, or as charter president from the date of charter to 30 june (six-month minimum), at the time of nomination.
Rotary Club(s)
Length of membership
Rotary year served as president
________________________
_________________
Year
____________
-
____________
________________________
_________________
Year
____________
-
____________
Phone (include country/city or area codes)
Fax (include country/city or area codes)
Residence
________________________________
Residence
_______________________________
Business
_________________________________
Business
_______________________________
Mobile
__________________________________
E-mail address (for RI Correspondence and publication in official Directory and international Assembly Participate books)
Preferred mailing address*
*if this mailing address is a post office box, please provide and alternate address for courier delivery.
Line 1
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Line 2
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Line 3
________________________________________________________
Line 4
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Country
________________________________________________________