District Officer Report Form

1

Civitan District Officer Report Form

District Governors-Elect: Please complete and return this form as soon as possible following the election or appointment of your 2015-2016 district officers (no later than September 30, 2015). Officers elected after that date (governors-elect, directors) should be submitted as soon as possible. Return this form to: Beth Towns, Membership-Leadership Department, Civitan International, P. O. Box 130744, Birmingham, AL 35213-0744, OR save to your hard drive and email to .

Civitan DistrictDistrict Number

Governor (201)

Name Spouse’s Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

Governor-Elect (202)

Name Spouse’s Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

Secretary (203) * (Send the secretary all invoices for dues and supplies? Yes No)

Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

Treasurer (205) * (Send the secretary all invoices for dues and supplies? Yes No)

Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

* Invoices may be sent to either the secretary or treasurer.If no indication is given, invoices will be sent to the district treasurer.

Judge Advocate (211)Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

Civitan Development Team — Task Force Leaders

New Club Building (220)Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

Existing Club Growth (221)Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

Existing Club Retention (222)Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

District Training Coordinator (209)Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

District Public Relations Chairperson (214)Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

Campus Club Chairperson (219)Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

Junior Civitan Chairperson (217)Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

Fruitcake Sales Promotion Chairperson (215)Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

Candy Box Project Chairperson (216)Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

Coin Box Project Chairperson (218)Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

District Bulletin Editor (210)Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

Awards Chairperson (212)Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

Meeting Planner (223)Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

District Webmaster (228)Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

NOTE: If your district has elected to combine the positions of district director and lieutenant governor,please skip to page 6.

District Board of Directors

District Director (Immediate Past Governor) (227)

Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

District Director (Elected Past Governor) (226)

Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

Additional Directors — In addition to the past governors (listed above) there shall be one (1) director elected for each (10) clubs or major fraction thereof, in good standing in the district. However, regardless of the number of clubs in the district, there shall be not less than three (3) directors elected for any district of Civitan International.

Director (208)Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

Director (208)Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

Director (208)Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

Director (208)Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

Director (208)Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

Director (208)Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

Director (208)Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

Director (208)Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

Please list all Lieutenant Governors/Area Directors and their assigned clubs.

Lieutenant Governor (207) Area Director (224)

Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

Assigned ClubsClub NumberAssigned ClubsClub Number

Lieutenant Governor (207) Area Director (224)

Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

Assigned ClubsClub NumberAssigned ClubsClub Number

Lieutenant Governor (207) Area Director (224)

Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

Assigned ClubsClub NumberAssigned ClubsClub Number

Lieutenant Governor (207) Area Director (224)

Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

Assigned ClubsClub NumberAssigned ClubsClub Number

Lieutenant Governor (207) Area Director (224)

Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

Assigned ClubsClub NumberAssigned ClubsClub Number

Lieutenant Governor (207) Area Director (224)

Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

Assigned ClubsClub NumberAssigned ClubsClub Number

Lieutenant Governor (207) Area Director (224)

Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

Assigned ClubsClub NumberAssigned ClubsClub Number

Lieutenant Governor (207) Area Director (224)

Name Spouse’s Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

Assigned ClubsClub NumberAssigned ClubsClub Number

Lieutenant Governor (207) Area Director (224)

Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

Assigned ClubsClub NumberAssigned ClubsClub Number

Lieutenant Governor (207) Area Director (224)

Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

Assigned ClubsClub NumberAssigned ClubsClub Number

Lieutenant Governor (207) Area Director (224)

Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

Assigned ClubsClub NumberAssigned ClubsClub Number

Lieutenant Governor (207) Area Director (224)

Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

Assigned ClubsClub NumberAssigned ClubsClub Number

Lieutenant Governor (207) Area Director (224)

Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

Assigned ClubsClub NumberAssigned ClubsClub Number

Lieutenant Governor (207) Area Director (224)

Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

Assigned ClubsClub NumberAssigned ClubsClub Number

Lieutenant Governor (207) Area Director (224)

Name

Mailing Address

City/State/Province Postal Code

Civitan Club Club # Email

Telephone: AC (B) (R) (Cell) (Fax)

Assigned ClubsClub NumberAssigned ClubsClub Number