District Seminar (Assembly)

District Seminar (Assembly)

Registration Form

Please complete this form and return by 21 April 2015, complete with payment.

Club Name: Rotary Club of
Refer to program for advice on sessions (copy attached)
Position in Club for the 2015-16 Rotary Year: / Name / Special Dietary Needs
President 2015-16
President Nominee i.e. President in 2016-17
Secretary
Treasurer
Membership Chair or Rep.
Public Relations Chair or Rep.
Rotary Foundation Chair or Rep.
Club Administration Chair or Rep.
Service Projects Chair or Rep. (See Introduction note on Program)
Chair of a District Committee in 2015-16
Chair of a District Committee in 2015-16
New Member in last 24 months
New Member in last 24 months
Other

Calculations:

Cost per Head / Total Number Attending / Total Amount to Pay
$25 / $ 0.00

Insert number of participants attending and press Tab key. Total amount payable will appear.

Checklist:
¨  Club name on form
¨  List of Rotarians names who are attending
¨  Any special dietary needs included
¨  Payment has been made [EFT preferred or cheque (see details below)
¨  EFT includes Reference to Club name
¨  Completed form emailed to by April 21st
Payment Details: Please pay District 9780 Treasurer per the instructions below:
1. EFT / OR / 2. Cheque
Rotary International District 9820 / Rotary International District 9780
BSB 035 070 (WestPac) / c/- District Treasurer,
Acc. No. 179130 / PO Box 358
Description "DA & YourClubname" / Ballarat Vic 3353
Registration Form: email completed form to District Governor Elect Jane Cox - / Registration Form: Attach completed registration form with cheque & post to above address

NOTE: In locations with more than one club please clarify specific club within the limited number of characters available e.g. for Geelong Central = DAGeelCent

Registrations Close: Monday, April 21 2015

Questions:

Howard Randall

Directions to the Event:

Stawell Secondary College - 79-97 Patrick Street, Stawell Vic 3380