Return to: Planning and Administration Division, The Rotary Foundation (No addenda are acceptable.)

/ The Rotary Foundation of Rotary International

Citation for Meritorious Service Nomination Form

Nominee Information

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Nominator Information

Name / Name
Street Address / Position in Rotary
City, State/Prov. / Street Address
Postal Code / City, State/Prov.
Country / Postal Code
Club / Country
District / Zone / Telephone
E-mail

The nominee is a: Ship plaque to:

Past District Governor, Year - / Name
Paul Harris Fellow / Address
Benefactor / City, State/Prov.
Major Donor / Postal Code
Other (Please explain): / Country

Please allow 6 to 8 weeks for processing. Nominations will not be accepted after 15 May.

If nominator is not the district governor, the nomination must have concurrence of the district governor.

District Governor’s Name (Please print)
District Governor’s Signature

NOMINEE’S SERVICE TO THE ROTARY FOUNDATION OF ROTARY INTERNATIONAL

The nominee has served on the following Rotary Foundation district committee(s):

District Rotary Foundation Committee, Year / - / Chair Year(s) / -

Subcommittees:

PolioPlus / Year(s) / - / Chair Year(s) / -
Foundation Information / Year(s) / - / Chair Year(s) / -
Group Study Exchange / Year(s) / - / Chair Year(s) / -
Alumni / Year(s) / - / Chair Year(s) / -
Scholarships / Year(s) / - / Chair Year(s) / -
Rotary World Peace Fellowships / Year(s) / - / Chair Year(s) / -
Grants / Year(s) / - / Chair Year(s) / -
Annual Giving / Year(s) / - / Chair Year(s) / -

The nominee has been actively involved in Rotary Foundation programs in the following ways:

Note that the following programs are (or were) TRF programs: Matching Grants; Health, Hunger and Humanity (3-H) Grants; (3-H Planning Grants); (Grants for Rotary Volunteers); (Children’s Opportunities Grants); (Disaster Relief Grants); (Grants for Rotary Peace Programs); (Carl P. Miller Discovery Grants); (District Designated Fund Discovery Grants); (New Opportunities Grants); (Helping Grants); (Individual Grants); District Simplified Grants; PolioPlus; PolioPlus Partners; Ambassadorial Scholarships; Rotary Centers for International Studies in peace and conflict resolution; Group Study Exchange; Rotary Grants for University for University Teachers. Service under other programs may not be a consideration for this award.

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Comments on nominee’s special contributions to the programs checked:

Group Study Exchange Team Leader / Year(s) / -
Alumni Activities / Year(s) / -
Scholarships / Year(s) / -
Selection Committee / Year(s) / -
Sponsor Counselor / Year(s) / -
Host Counselor / Year(s) / -
Rotary Centers for Internat’l Studies / Year(s) / -
Matching Grants / Year(s) / -
Project Contact on Matching Grant Number(s):
Volunteer Service, District Simplified, (Individual), or (Discovery) Grants / Year(s) / -
3-H Grants / Year(s) / -
Project Contact on 3-H Grant Number(s):
PolioPlus / Year(s) / -
National Committee Chair / Year(s) / -
PolioPlus Partners / Year(s) / -
Rotary Volunteer / Year(s) / -
Other Foundation Programs:
/ Year(s) / -

The nominee has been involved in the following fundraising activities for The Rotary Foundation at the district level:

Please mail or fax nomination form to:

Or e-mail form to trustee service / Administration Department
The Rotary Foundation, One Rotary Center
1560 Sherman Avenue, Evanston, IL 60201-3698 USA
Fax: 847-491-9364

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