Updated September 2015

The Delta Kappa Gamma Society International
Xi State, Tennessee

Nomination for the Xi State Order of the Rose

Application Deadline: March 15, 2016
Instructions: This application utilizes a table format and is designed to expand as you type. Point and click with your mouse to enter information.
· This recognition is for members who have made outstanding contributions to chapter and community, but who have not received recognition at the state level through other means.Up to 12members will be recognized during the Xi State Convention.
· The nominee shall have been an active participating member for at least 15 years.
· Only one member may be nominated per chapter.
· A picture of the nominee must be included with the nomination form.
· Honorees are honored at the annual Xi State Convention and must register for and attend the convention.
· All written parts of the application must be submitted together and received by March 15.
· Note: Chapters must include a check for $20 with the application to help defray part of the cost for the Order of the Rose pin guard. If an applicant is not selected, the $20 will be returned to the chapter. This check must be received by the committee chair by March 15.
Personal Data
Name of the nominee: (Dr., Mrs., Ms.)
Mailing Address:
City, State, Zip Code:
Email address:
Chapter Affiliation: Year initiated into Society:
Involvement
CHAPTER OFFICER- 5 points for each office per year (if serving the same office more than once, give five points for each biennium).The officers are President, 1st Vice President, 2nd Vice President, Recording Secretary and Corresponding Secretary, Treasurer. Please list office(s) and date(s):
Total points for this section: ______
CHAPTER COMMITTEE CHAIR- 3 points for each chairmanship per year. Please list committee(s) and date(s):
Total points for this section: _____
CHAPTER COMMITTEE MEMBER- 2 points for each committee per year. Please list committee(s) and date(s):
Total points for this section: _____
Community Involvement:
COMMUNITY SERVICES- 1 point for each service per year. -Please describe in detail with dates.
Total points for this section: _____
CHURCH SERVICE- 1 point for each position or teaching assignment per year. Please describe in detail with dates.
Total points for this section: _____
OFFICER in a COMMUNITY CLUB- 2 points for each position per year. Please describe in detail with dates.
Total points for this section: _____
MEMBERSHIP or OFFICER in PROFESSIONAL ORGANIZATIONS-1 point per organization per year, 2 points per office held. Please list with dates.
Total points for this section: _____
In 1-2 paragraphs (limited to a total of 100 words), please write the tribute you would like to have printed in the event your nominee is chosen. Tributes exceeding 100 words will be edited at the discretion of the awards committee. (This must be emailed to the committee chair.)
Submitted by:
Position in the chapter:
Street Address:
City, State, Zip Code:
Telephone number:
Email Address:
Recipients will be selected based on the greatest number of total points. Please fill out the application completely and as detailed as possible to ensure your nominee has the greatest chance of being selected.
In order for a nominee to be considered eligible, all four parts must be submitted and received by March 15, 2015:
·  Application (preferably emailed)
·  Photo (must be emailed)
·  Tribute (must be emailed-see page 3 of application)
·  Check for $20 payable to Xi State
Send to:
Wynona Clayborne
Awards Committee Chair

8295 Scottsville Rd., Lafayette, TN 37083
615-666-5410 or 615-888-6559
Call or email if you have any questions.

* A check payable to Xi State for $20.00 must be received by March 15. This fee will be used toward the purchase of the Order of the Rose pin guard. If an applicant is not selected, the $20 will be returned to the chapter.