Certification for Chartering a Civitan Club
Club Name:District:
Attached is the typed or printed Charter Membership List listing the name, correct mailing address, and sponsor of each charter member as well as the former club of each transfer or reinstated member and the charter application form.
A copy of the club’s proposed budget and newsletter or bulletin and Bylaws as approved by the district Judge advocate must be attached (not necessary to get judge advocate’s approval if using Standard Form Bylaws, CL125).
The new club will meet: (a) How many times per month: (b) Day of week: (c) Time
(d) Place and address:
If not meeting every week, will the club meet: 1st week2nd week3rd week4th week5th week
List of Officers:
If the preferred mailing address or telephone number for an officer is different than his or her address on the attached membership roster and all mail is not being sent to the club post office box, please indicate the preferred address or telephone number on the back of this form.
3-2009Certification for Chartering a Civitan Club
President:
President-Elect:
Secretary:
Treasurer:
Billing Contact:
Check One:
All mail for Pres Sec Treas should be sent to
Club Post Office Box:
City/State/Province/Postal Code
All mail should be sent to individual’s address.
Director:
Director:
Director:
Additional Directors:
Chaplain (Optional):
Sergeant-at-Arms (Optional):
Committee Chairpersons:
Program
Growth & Retention Mgr.
Fund Raising:
Projects:
Publicity/PR:
3-2009Certification for Chartering a Civitan Club
Lieutenant Governor or Area Director for new club:
3-2009Certification for Chartering a Civitan Club
Name of District Training Coordinator who trained the new club’s officers:
Date of training:
3-2009Certification for Chartering a Civitan Club
The New Club Development Team Leader for the first full year is:
Telephone: AC (B) (R)
Address:
City: State/Province: Postal Code:
The new club has an established bank account at the bank.
The club’s official post office box mailing address is:
3-2009Certification for Chartering a Civitan Club
According to Civitan International Policy, no more than
- three Accredited/Certified Club Builders can be recognized for any one club chartering with 20 to 29 members
- four for any one club chartering with 30 to 39 members
- five for any one club chartering with 40 or more members
(The club builders will receive credit for building this club in the order they are listed, unless the governor notifies Civitan International in writing of the change within 30 days after the charter date. For example if the club charters with only 30 members, the fifth builder listed will not be credited as a club builder.) The Accredited/Certified Club Builder(s) for this new club and their clubs are:
Name/ Civitan Club
Name/ Civitan Club
Name/ Civitan Club
Name/ Civitan Club
Name/Civitan Club
Preferred mailing addresses for officers if mail is being sent individual’s address and the preferred address is different than address shown on attached membership roster:
Name/Office/Preferred Address
Name/Office/Preferred Address
Name/Office/Preferred Address
Name/Office/Preferred Address
Name/Office/Preferred Address
3-2009Certification for Chartering a Civitan Club