Form H
Spouse Information (if applicable)
Mail
Femail
Title (e.g. Mr/Ms/Mrs/Dr/Rev)
______________________________________________
Suffix (e.g. Jr/Sr/III) ___________________
Family Name
___________________________ First Name ________________________ Middle initial ________________________
Name as it should appear on your badge
____________________________________________________________________________
Phone
_____________________________ E-mail ____________________________________ Fax ___________________________
Language fluency for International Assembly disussions (choose one):
Chinese
English
French
German
Hindi
Itallian
Japanese
Korean
Portguese
Spanish
Swedish
Language preference for RI mailings (choose one):
English
French
Japanese
Korean
Portguese
Spanish
For Rotarian spousers only :
Spouse ID number
___________________________
Member Rotary, club of
_______________________________
Highest office held________________________
(official name of club, including country)
________________________________________________________________________________________________________
Photos
If you are selected as governor-nominee, RI will need a head-and-shoulders photograph of you and of your spouse (individually, not as a couple) for the International Assembly Participates book, Digital photos in high-resolution. jpg format are preferred, E-mail your photo, along with your full name, district number, and the Rotary year in which you will serve, to dgn.photo@rotary.org. Photos are due by 30 June.
If you choose to submit a hard-copy photograph, it must measure as least 4 x 5in/10 x 12.5cm. The photo with your full name, district number, and the Rotary year in which you will serve clearly printed on the back must be submitted with this form.Please indicate how your photos are being submitted:
Digital photos e-mailed to dgn.photo@rotary.org
Hard-copy photos attached (do not staple photo of this form)