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                                                                                 ALTRUSA INTERNATIONAL, INC. DISTRICT SIX

Governor’s Award

Nomination Form

Please print or type all information.  The back of this sheet may be used for additional information.

Nominee’s name: __________________________________ Altrusa International, Inc. of _______________________________

Address _______________________________________ City ________________________State ____ Zip ________________

Nominee has been a member of Altrusa International, Inc.?                                             (Altrusan has been a member for ten years or more.)

Activities during the past 10 years:

Positions held in Local Club (with dates) _______________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

Positions held at District Level (with dates) ­­­­­­­­­_____________________________________________________________________

_______________________________________________________________________________________________________

Positions held at International Level (with dates) ________________________________________________________________

_______________________________________________________________________________________________________

No. of new members sponsored _______ Workshop presentation ___________________________________________________

                                                                                                                                                (enter title & event)

Member of Club 21:  No____ Yes ____ Years________ Donations to Altrusa Int. Foundation:  No___Yes____ Years__________

 

District Conference

(enter years):

>>> 

Attended

 

As Delegate

 

As Alternate

­­­­­­­­­­­­­­­­

Int. Convention

(enter  years):

>>> 

Attended

 

 

As Delegate

 

 

As Alternate

 

 

 

Write brief description of major projects chaired by nominee_______________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

Write brief description of minor projects chaired by nominee________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

Activities during the past year:

No. of Club Meetings Held:

No. Attended by Nominee:

No. of Community Service Hours by Nominee:

No. of Member Service Hours by Nominee:

No. of  Other Volunteer Hours by Nominee:

 

Please complete a 500 word essay about this nominee and send it with the completed information.  Include how they have demonstrated leadership as an Altrusan and made a difference to Altrusa.

 Entry must be postmarked by March 10, 2012 and returned to:  Toni Ellis, 1912 Williamsburg Road, Lexington, KY, 40504-3014 or emailed to Toni_ellis2001@hotmail.com

 Date:                                       Altrusa International, Inc. of: ___________________________________

                                                  Submitted by: _______________________________________________