Application Form - Ambassador Of Goodwill Award printable pdf download

Application Form - Ambassador Of Goodwill Award

Ambassador of Goodwill Award

A new district/club level award honoring Rotarians who travel to another

country at their own expense to further the goals and objectives of Rotary

Application Form

This application form is to be filled out by the traveling Rotarian and submitted to

the Chair of the District Friendship Exchange Committee or the District

Governor’s designee. The application form can be faxed, printed out and mailed or

filled out and returned by e-mail. For further information call or e-mail your Chair

of the District Friendship Exchange committee.

(Please type or print.)

1. Traveling Rotarian’s Name__________________________________________

2. E-mail Address _____________________________Phone (___)___________

3. Rotary Club Name________________________________________________

4. Rotary Club President’s name_______________________________________

5. Rotary Club President’s mailing address_______________________________

__________________________________________________________________

6. Rotary District___________________________________________________

7. Purpose of Rotary Travel___________________________________________

__________________________________________________________________

_________________________________________________________________

8. Rotary Club(s)/District(s)/Country visited_______________________________

__________________________________________________________________

9. Dates of Travel___________________________________________________

10. Comments (optional but appreciated – use separate page if necessary)________

__________________________________________________________________

(May we use these comments in promoting this Award?) Yes____ No____

11. Number of extra pins for traveling spouse and/or children _______

12. Multiple award number (2

, 3

, 4

, etc., if applicable)__________

Rev 3/26/08

Application Form - Ambassador Of Goodwill Award