ALTRUSA INTERNATIONAL, INC., DISTRICT SIX

 NOMINATION FORM FOR DISTRICT SIX

Name                                                                                                                         

 Altrusa International, Inc. of                                                                           

 Address                                                                                                          

 City                                                                                            State ______   Zip Code                              

Home Phone                                         Office                                      E-Mail ______________________

SELECT YOUR CLUB NOMINATION AS LISTED: 

              District Nomination Committee

 ______ International Nomination Committee

 ______ International Foundation Board of Trustees

 PREVIOUS CLUB LEADERSHIP:             Club President          Dates Served:                                    

 OTHER ALTRUSA OFFICES AND ACTIVITIES:   

  PERSONAL AND PROFESSIONAL INFORMATION:   

Submitted by_________________________________

Altrusa Int’l of_________________________________

 MAIL TO:       Nancy Easum

                        District Six Nominating Committee

                        3500 St. Francis Drive

                        Springfield, IL  62703

MUST BE POSTMARKED BY October 31, 2011