Spirit of Rotary Nomination Form

Name of Nominating Rotarian *

First Name

Last Name

Name of Nominee *

First Name

Last Name

Is nominee under age 40 at time of nomination? *

Yes

No - does not qualify

Nominee phone

(###)

###

####

Nominee address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date first active in community *

MM

DD

YYYY