New Club Building Team

Golden Circle Charter Funds

Disbursement Form

The New Club Building Team will be those club builders designated by the district board as the recognized club builders. Civitan International will send the following monetary reward to the club builders for chartering the new club as requested below:

¨ When a new club building team charters a club with 30 members, the building team will be awarded $250 and the new club will be awarded $250.

¨ For each additional 5 charter members, the building team and the new club will each be awarded an additional $25.

Name of New Club:

Charter Date:

Number of Charters Members*:

This New Club Building Team qualifies to receive: q$250 q+$25 x (# charter members–30)/5= Total $

The New Club qualifies to receive: q$250 q+$25 x (# charter members–30)/5= Total $

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Please check one or more ways the team wants to distribute their portion of the funds:

qOne or more team members (indicate amounts below)

qNew club—portion to be received $ Mail check(s) to (name)

qSponsoring club portion to be received (if more than one list separately by name) $ Mail to

Form must be signed by every recognized team member. (The signatures will confirm agreement on how to disburse the funds.)

Club Builder:

Complete Address:

Portion To Be Received $ Signature

Club Builder:

Complete Address:

Portion To Be Received $ Signature

Club Builder:

Complete Address:

Portion To Be Received $ Signature

Club Builder:

Complete Address:

Portion To Be Received $ Signature

Club Builder:

Complete Address:

Portion To Be Received $ Signature

* For purposes of this incentive, the following determination of charter membership will be strictly enforced.

The charter membership will be the number of members whose names and initiation fees have been submitted to Civitan International within 14 days of the charter date of the new club. A minimum of 70% of charter members must pay full dues.

Return To: Membership-Leadership Department, Civitan International, P. O. Box 130744, Birmingham, AL 35213-0744

Fax: (205) 592-6307 E-Mail:

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