District Governor Nominee Designate Application
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Rotary Club
*
Please Select
AnSeOx
Branford
Bridgeport
Cheshire
Chester
Clinton
Danbury
Darien
Deep River
Derby-Shelton
Devon
East Hampton
East Haven
Essex
Fairfield
Greenwich
Groton
Guilford
Hamden
Ledyard
Madison
Meriden
Middletown
Milford
Monroe
Montville
Mystic
Naugatuck
New Canaan
New Haven
New London
Newtown
Niantic
North Branford
North Haven
Norwalk
Norwich
Norwich Sunrise
Old Saybrook
Orange
Ridgefield
Stamford
Stoningtons
Stratford
Tribury
Trumbull
Wallingford
Waterbury
Waterford
West Haven
Westport
Westport Sunrise
Wilton
Woodbridge
Membership Start Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What years were you President of your Club?
*
Ex: 1995-1996, 2000-2001
Tell us about yourself
Have you served in any of the following roles? (Check all that apply)
Assistant Governor
District Committee Chair
District Foundation Subcommittee Chair
Club Committee Chair
Other
Have you achieved any of these donation levels? (Check all that apply)
Sustaining Member
Paul Harris Society
Benefactor
Paul Harris Fellow
Major Donor
Arch Klumph Society
Endowment, Estate, or Legacy
Directed gift
Other
Have you received any of the following recognitions? (Check all that apply)
Abraham I Gordon Award
Donald A. Adams Award
Donald MacRae Peace Award
Norm Parsells Award
Service Above Self Award
Rotarian of the Year
Unsung Hero
Other
How would you rate your skill with email, phone, text, and group messaging?
Not strong
1
2
3
4
Excellent
5
1 is Not strong, 5 is Excellent
How confident are you in navigating My Rotary and using Rotary Club Central and its reports?
Not strong
1
2
3
4
Excellent
5
1 is Not strong, 5 is Excellent
How much have you used and engaged with the Learning Center courses?
Not at all
1
2
3
4
Completed all
5
1 is Not at all, 5 is Completed all
Club & Data Management Competencies (Check all that apply):
Can you manage and organize detailed data using Excel or similar tools?
Have you helped others submit an MOU or set Annual Giving Goals in Rotary Club Central?
Are you comfortable preparing event or project budgets?
Have you used DACdb, ClubRunner, or your club’s database to update info or run reports?
Describe a few Club or District activities you are most proud of accomplishing?
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Looking Forward Vision Questions
(less than 150 words please)
What ideas do you have for making the District more visible—both within Rotary and throughout our Clubs?
0/150
Which District priorities do you feel need the most attention right now?
0/150
How would you inspire and strengthen Foundation giving and engagement across our district?
0/150
How would you inspire and grow membership across our district?
0/150
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CLUB’S STATEMENT OF CANDIDATE’S QUALIFICATIONS
Please President and Secretary will receive a notication to approve your application
Applicant Club Secretary
*
Name of Reference
Secretary Email
*
example@example.com
Secretary Phone
Applicant Club President
President Email
example@example.com
President Phone
Bio or Resume
Optional but helpful
Please Upload Your Resume, Bio, or pertinent documentation
Upload a File
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of
Certification
I certify the information is accurate and complete.
Signature
Signature of applicant (can be typed or drawn)
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