To: Planning and Administration Division, The Rotary Foundation

Deadline for nominations: 15 November. The Trustees will consider all nominations at their January/February meeting. Nominators will be notified of the Trustee decision as soon as possible after the meeting. Plaques will require 10 weeks for delivery. Please be as specific as possible when describing the nominee's activities on this form. (No addenda are acceptable; however, fields will expand when you type.)

Nomination Form

Nominee Information

Name \ Rotary ID No.

Rotary ClubDistrict Zone

Past District Governor, Year -

Year Nominee received the Citation for Meritorious Service

MUST be in the 2002-2003 Rotary year or prior

The nominee is a:

Paul Harris Fellow  Multiple Paul Harris Fellow

Benefactor Bequest Society Member

Sustaining Member

Major Donor Arch Klumph Society Member

Other (Please explain):

Nominator Information

(Either the Nominator or the Endorser must be from outside the Nominee’s District.)

Name

Position in RotaryDistrict

Address

StreetCity/State/Postal CodeCountry

Telephonee-mail:

area codearea code

Signature of Nominator

Endorser’s NameDistrict

Signature of Endorser

Address:

Ship recognition plaque to: (Please leave blank if this is the same as the Nominator.)

Name Telephone:

Address e-mail:

NOMINEE’S SERVICE TO THE ROTARY FOUNDATION OF ROTARY INTERNATIONAL

To receive a Distinguished Service Award, the recipient's service must constitute more than donations to The Rotary Foundation. The recipient must show service on a broad basis, over an extended period of time, including at least three of the following activities, with a substantial level of activity in the past four years:

  1. serving on the District Rotary Foundation Committee or a subcommittee for a total of at least five years:

District Rotary Foundation Committee Year(s - Chairman Year(s) -

Subcommittees:

PolioPlusYear(s) - Chairman Year(s) -

Foundation InformationYear(s) - Chairman Year(s) -

Group Study ExchangeYear(s) - Chairman Year(s) -

AlumniYear(s) - Chairman Year(s) -

ScholarshipsYear(s) - Chairman Year(s) -

Rotary World Peace FellowshipsYear(s) - Chairman Year(s) -

GrantsYear(s) - Chairman Year(s) -

Annual GivingYear(s) - Chairman Year(s) -

b. providing significant leadership at district or multi-district Foundation training events (such as District Assemblies or P.E.T.S.);

c. presenting Foundation programs at district or regional events (such as District Conferences, Foundation seminars, or Zone Institutes);

d.presenting Foundation programs at more than twenty club meetings within a two year period;

e.serving as a Scholar counselor and/or GSE host at least three times;

f.organizing and carrying out successful fund raising efforts at the district or multi-district level;

g.providing significant leadership in district or multi-district scholar and GSE team orientation;

h.serving as the designated project contact person for a successful 3-H or Matching Grant project for which a final report has been received;

i.providing substantial leadership in PolioPlus projects and activities;

j.serving as an international volunteer and receiving a Rotary Foundation Grant for Rotary Volunteers;

k.maintaining contact with Foundation alumni and involving them in district activities;

  1. other special projects or activities in support of the Foundation's programs and activities (must be clearly defined and described in detail by the nominator).

District Governor’s Endorsement:

I have reviewed this nomination and endorse it.

Signature of District Governor Date:

District Governor

Please mail or fax nomination form to:

Distinguished Service Award

Planning and Administration Division of The Rotary Foundation

One RotaryCenter, 1560 Sherman Avenue

Evanston, Illinois 60201-3698 USA

Fax: 1-847/ 491-9364