ROTARY INTERNATIONAL DISTRICT 6780

ROTARY INTERNATIONAL DISTRICT 6780 NOMINATING COMMllTEE FOR DISTRICT GOVERNOR FOR DISTRICT 6780 For the selection of a District Governor to Serve in Rotary Year 2016-17 In accordance with the By-Laws of Rotary lnternational and the Rules of Procedure of this district, and on behalf of the Nominating Committee for District Governor, this form is provided for use by any club in this district desiring to submit for consideration of the Nominating Committee, a suggestion for Governor of District 6780. Include only the Governor-Nominee Data Form with this form. Do not attach any other pages or information that is not requested. Any Club wishing to submit a name should refer to the provisions of Articles X and XIII of the Rotary lnternational By-Laws and to Rule 1 of the District Rules of Procedure. As provided in Article X of the By- Laws of Rotary lnternational brochures, literature, or letters are not to be distributed or circulated by a candidate for nomination as District Governor, or by others in his/her behalf to any clubs or members of clubs. The By-Laws provide that the Board of Rotary lnternational shall disqualify from election any candidate who violates the prohibition against campaigning or canvassing. SUGGESTION TO NOMINATING COMMllTEE FOR DlSTlCT GOVERNOR Any club desiring to submit a suggestion must complete this form and the Governor-Nominee Data Form, including all requested information, and mail to: PVlVP John Germ, Chair District 6780 Nominating Committee 651 East Fourth Street, Suite 600 Chattanooga, TN 37403 so as to be received at this address no later than December 19,2013. Enclosures 1. Form H: Governor - Nominee Data Form 2. District 6780 - Information Regarding District Governor Expenses 3. District 6780 Statement of Receipts and Disbursements through June 30, 2012 4. James L. Bomar, Jr. Rotary Interact Scholarship Foundation -June 30, 2012

[rn\ @ Form H: Governor-nominee Data Form Page 1 of 4 District governor candidate: Please complete and sign this form, have your club secretary sign it, and submit it to the district nominating committee. Governor year District Zone Title (e.g., Mr/Ms/Mrs/Dr/Rev) Suffix (e.g., Jr/Sr/III) Family name First name Middle initial Call name as it should appear on your badge Male [7 Female Single Married [7 Widowed [7 Divorced City, country, and year of birth Member, Rotary Club of (official name of club, including country) p membership ID number Year you first joined Rotary Current (or former, if retired) classification Current (or former, if retired) firm and position If retired, year of retirement I Per RI Bylaws 15.070.3, a qualified Rotarian must have served a full term as club president, or as charter president from the date of charter to 30 June (six-month minimum), at the time of nomination. I Rotary club(s) Length of membership Rotary year served as president Years Years Phone (include country/city or area codes) Residence Business Fax (include country/city or area codes) Residence Business Mobile E-mail address (for RI correspondence and publication in Oficial Directory and International Assembly Participants book) Preferred mailing address* *If this address is a post office box, please provide an alternate address for courier delivery. Line 1 Line 2 Line 3 Line 4 Country

Page 2 of 4 orm H Alternate mailing address Line 1 Line 2 Line 3 Line 4 Country Language Preferences Language(s) you wish to use for communicating with RI (listed in order of fluency): Read Speak For each of the following, please choose one: International Assembly sessions I7 English 17 French 17 Japanese Korean Portuguese Spanish Rotary publications produced in 6 languages English French Japanese Korean Portuguese Spanish Rotary publications produced in 9 languages English French rn German Italian [7 Portuguese Spanish Swedish Japanese rn Korean Rotary publications produced in 12 languages Chinese English Finnish French 17 Korean Portuguese I7 Spanish Swedish German Thai Italian Japanese Personal History (please do not use abbreviations) Business and Professional Organizations (listed in order of importance; use an additional sheet of paper, if necessary): Organization Office Dates Office Held Dates of Membership Social and Civic Organizations (listed in order of importance; use an additional sheet of paper, if necessary): Organization Office Dates Office Held Dates of Membership Business/Professiona1 Career (please provide a brief outline, including each firm and dates): Principal Hobbies (list two):

Page 3 of 4 Form H Spouse Information (if applicable) Male Female Title (e.g., Mr/Ms/Mrs/Dr/Rev) Suffix (e.g., Jr/Sr/III) Family name First name Middle initial Name as it should appear on your badge Phone E-mail Fax Language fluency for International Assembly discussions (choose one): Chinese English French [7 German Japanese Korean Portuguese [7 Spanish Hindi Swedish [7 Italian Language preference for RI mailings (choose one): English French Japanese Korean [7 Portuguese Spanish For Rotarian spouses only: Spouse ID number Member, Rotary Club of (oficial name of club, including count4 Highest office held Photos If you are selected as governor-nominee, RI will need a head-and-shoulders photograph of you and of your spouse (individually, not as a couple) for the International Assembly Participants book. Digital photos in high-resolution.jpg format are preferred. E-mail your photo, along with your full name, district number, and the Rotary year in which you will serve, to dgn.photo@rotary.org. Photos are due by 30 June. If you choose to submit a hard-copy photograph, it must measure at least 4 x 5 in.110 x 12.5 cm. The photo with your full name, district number, and the Rotary year in which you will serve clearly printed on the back must be submitted with this form. Please indicate how your photos are being submitted: Digital photos e-mailed to dgn.photo@rotary.org Hard-copy photos attached (do not staple photo to this form)

Page 4 of 4 Form H All signatures on this page must be handwritten (electronic signatures are not acceptable). CANDIDATE'S STATEMENT I hereby state that I understand clearly the qualifications, duties, and responsibilities of the office of district governor as set forth in the RI Bylaws and that I am fully qualified for said office and willing and able, physically and otherwise, to assume and fulfill the duties and responsibilities of that office and to perform them faithfully. Further, I have read and agreed to abide by the district governor code of ethics, as detailed in the Rotary Code of Policies. I understand that if selected, I must attend, for their full duration, the govemorselect training seminar in my zone and the International Assembly to be held the Rotary year before taking office. I have read this fonn in its entirety and certify that all the information provided on this form is true and correct. Date Signature CLUB'S STATEMENT OF CANDIDATE'S QUALIFICATIONS The candidate herein mentioned is a member in good standing of the Rotary Club of. The club further attests that this member has been duly suggested for the office of district governor under RI Bylaws 13.020.4 and meets the qualifications as specified in RI Bylaws 15.070 and that the club membership information on this form is accurate. Date Club Secretary's Name Club Secretary's Signature CERTIFICATE OF DISTRICT NOMINATING COMMITTEE The undersigned members of the District Nominating Committee hereby certify that the candidate whose name appears on this form, to the best of the committee's knowledge, has not violated any of the rules on campaigning, electioneering, or canvassing as stipulated in RI Bylaws 10.060. (If the committee has more than five members, please attach a separate list.) Names Signatures CERTIFICATE OF NOMINATION The Rotarian named on this form is a member in good standing of the Rotary club listed and was duly nominated for district governor in accordance with the provisions of the RI Bylaws. Date District Governor's Name District Governor's Signature District governor: Please mail, fax, or e-mail all pages of this form, including any additional sheets or photos, to your CDS representative by 30 June.

Rotary District 6780 - Information Regarding District Governor Expenses Serving as District Governor need not be a financial hardship for anyone. Rotary lnternational determines an allocation for the District Governor. For District 6780 the allocation has been approximately $11,500 in recent years. The current RI guide for eligible expenses appears below. In addition, Rotary lnternational pays for the cost of the DGE and spouse to attend the required lnternational Assembly in January of the DGE year. In addition, the District Budget provides for many other expenses incurred by a DGN, DGE and DG including: D D D Training and attendance at the annual Rotary Zones 30-31 Institute during the DGN, DGE, and DG years. Includes spouse. Expenses (for DGE and spouse) to attend the Rotary lnternational Convention during the DGE year. Supplement to attend (for DG and spouse) the Rotary lnternational Convention during the DG year. Discretionary fund for the DG -currently $2,000 Discretionary fund for the DGE and DGN -currently $750 and $500 respectively. Various other accounts that can be used for training and other purposes. DistrictGovernorExpenseGuide (From RI District Governor Manual 2014) This guide is the primary resource in completing your governors' allocation expense reports. Separate expense reports are used for Governors-elect Training Seminar, Assistant Governor Training, and costs associated with organizing new clubs. Please ask your Club and District Support Representative (www.rotarv.or~/cds) any questions concerning reimbursable expenses. In general, if an expense is not listed as eligible, it is not reimbursed. Eligible Extlenses as District Governor-nominee Reimbursable 24 to 13 months before you take office as governor: Printing of governor business cards and stationery, letterhead and envelopes (Report A) Travel expenses for conductingsite visits for your district conference, including automobile transportation (Report E), lodging and meals (Report F), and airfare (Report G) Note: Only the expenses outlined above are eligible for reimbursement from RI as a governor-nominee. Eli~ible Extlenses as District Governor-elect Reimbursable 12 months before you take office as governor: Printing and Copying Governor business cards and stationery, letterhead, and envelopes (Report A) r Handouts and promotional materials for district training meetings including district team training seminar, district assembly and president-elect training seminar [PETS] (Report A) Postage Club Officers' Kit (225) to club presidents-elect for PETS, including customs duty (Report B) Promotional materials for PETS and district assembly (Report B)

Travel Expenses Planning and conducting the district team training seminar, district assembly, and PETS, including personal automobile transportation (Report E), lodging and meal expenses (Report F), and necessary airfare and registration fees (report G) Conducting site visits for your district conference, includingautomobile transportation (Report E), lodging and meal expenses (Report F), and airfare (Report G) Official Duties r Theme pins, banners, gifts, RI theme jacket (Report G) Reimbursable 6 months before taking office asgovernor: Phone, fax, internet line/access, mobile phone account (Report D) Necessarycomputer software for Rotary business use (Report C) Note: Only the expenses outlined above are eligible for reimbursement from RI as a governor-elect.

Eligible Ex~enses as District Governor Below are details of all eligible expenses and some examples of ineligible expenses for governors. Eligible Expenses Ineligible Expenses Report A - Printing and Copying Business cards and stationery, letterhead, and envelopes Production of governor's monthly letter Copyingof district-level election materials E-newsletter subscription costs for governor monthly letter 0 Creation of Web site and Web hosting a Any RI or Rotary Foundation publications or materials Handouts and promotional materialsfor district meetings (team training seminar, district assembly, PETS, and district conference) District directory Greeting cards Report B - Postage a a Governor's monthly letter to club and district officers (if not done using online software) Personal correspondence to clubs, assistant governors, and district committees Materials to RI (expense reports, Memos of Club Visit, etc) RI or Rotary Foundation materials Promotional materials for district conference, PETS, and district assembly District-level election materials Customs duty on materials sent from RI District directory Greeting cards and gifts Report C - Office Supplies General office supplies such as paper, envelopes, notebooks, pens, pencils, paper clips, staples, toner, ink cartridges, and USB drives r Necessary computer software for Rotary business use, including online meeting software a Purchase or lease of equipment (telephone, personal computer, laptop, printer, copier, projector, scanner, and digital camera) Computer support services Service contracts for computers or for other equipment r Repairs to computer or other equipment Greeting cards and gift wrap

Eligible Expenses Ineligible Expenses Report D - Telephone and Fax Monthly usage for each one of the following: phone, internet, fax and cell phone Internet access (such as AOL, An, MSN, Verizon, etc) Installation of high-speed services, such as DSL, cable, or wireless Installation of additional lines (internet, fax, or phone) Repairs Report E - Auto Travel Log and Mileage Official visit and any additional visits to each Rotary club Planning, conducting, and attending your district conference Attending membership seminar, PETS, district assembly, and district leadership seminar Any Rotary Foundation-related meeting District committee meetings or seminars Travel associated with any RI or Foundation program (Group Study Exchange, Interact, and Rotary Community Corps) Report F - Hotel and Meals Hotel/lodging expenses while conducting official duties - see E (Hotel folio required for all hotel/lodging expenses, regardless of amount) Personal meal cost for attendance at committee meetings, Group Study Exchange, RYLA events, etc. Host/hostess gift in lieu of hotel (cannot exceed US$25) Celebrations/parties (for holidays, installations, RI president or his representative visit or meeting) Travel outside the district other than for own district conference or your district PETS if multidistrict Travel to Rotary Institute, International Institute, RI Convention, or other District Conferences Hotel and meal expenses for spouse, partner, or any other individual r Expenses associated with activities not covered in E Report G - Miscellaneous Airfare needed to perform official duties Ferry boats, taxis, trains Tolls and parking fees Visas and official permits Registration fees for district conference, PETS, district assembly and district team training seminar. Dry cleaning or laundry associated with official duties Awards, theme pins, banners, frames, gifts, and plaques Translation services or equipment RI theme jacket r Automobile repair costs, oil, gas, car washes, etc. Expenses related to Rotary Institute, RI Convention, and other District Conferences Grooming services, such as haircuts and manicures, etc. Medicalexpenses Office space or office furniture (rental or purchase) Secretarial or clerical services

ROTARY INTERNATIONAL DISTRICT 6780 STATEMENT OF DISBURSEMENTS THROUGH JUNE 30,2012 DISBURSEMENTS: Rules 08-09 Reference - Actual International Convention: DGE & Spouse 3.2d, 4.3abcd DG & Spouse Rotary Zone Institute: DG & DGE Training Reg. RI, DGN Training Reg. DG & Spouse Travel 10.1, 10.2 DGE & Spouse Travel 10.1, 10.2 DGN & Spouse Travel 10.1, 10.2 District Trainer Travel Zone Success Seminars District Conference Exp. (Net) 3.2.a District Governor Gift 3.2.c District Governor Pin 3.2.c GSE at District Conference Ambass Schol at Dist Conf District Governor: RI Allocation Discretiona~y Fund District Directoly Assistant Governor Expenses Mid-Year Leadership Conf District Governor Elect: Expenses Pre-PETS Assistant Governor lnstitute Presidents-Elect Training 3.2.b District Assembly 3.2.b PETS Alliance (Evanston) Committee Expenses: Gmup Study Exchange (Net) Awards of Excellence 7 Arnbassad & Peace Scholars Rotary Foundation Gates Challenge, Polio Erad. 3.3.e Technology & Web Site Public Relations matching grant & events Membership Dev & Ext Service Projects 3.3.e Vocational Service Committee Other Committees InSl Director Nominating Disaster Response Youth Programs: Youth Program Coord. Interact 3.3.e Fred Brown lnteract Award 11 Rotaract lntl Youth Exchange Vocation Services Awards College of Governors - W~nter District Treasurer: Expenses 3.2.9 Bond 3.7 AuditIReview 3.6 Seminars Found, Mernb 8 New Gens Materials and Meetings Dist Leadership Academy Tmg 3.2.b RLI & Zone Dues 3.2.9 Memorials 3.2.f, 15 District Administration 3.2.9 District Administration Exps. 3.2.9 Zone lnstitute Contribution TOTAL DISBURSEMENTS CH 2868 "OFFS!3TING RECEIPT "FINANCE COMMITTEE AUTHORIZED OVEREXPENDITURE DG LaRue Foster Davis Rothermel Rothermel Institute Indianapolis Tulsa Nashville St. Louis St. Louis Assembly San Diego San Diego San Diego San Diego San Diego Convention Birmingham Montreal New Orleans Bangkok Bangkok Membership 3,534 3,514 3.690 3,327 3,287

JAMES L. BOMAR JR., ROTARY INTERACT SCHOLARSHIP FOUNDATION Balance - June 30.201 1 Contributions Rotary West Knoxville (Hon-F Rothermel) $500 McMinnville Rotary Club 250 McMinnville Rotary Club 250 Cleveland Rotary Foundation 500 Rotary Club of Tellico Lake 100 Cookeville Breakfast Rotary Club (Hon-F Rothermel) 100 Memorials Bobby & Debbie Davis (Mem-W Howard Buckner) $ 50 District 6780 (Mem-W Howard Buckner) 100 District 6780 (Mem-Max R Carroll) 100 District 6780 (Mem-Mary Frances Bailey) 100 Interest Earned Scholarships Taxes & Expenses Balance - June 30.2012 (Corpus = $178,914) ON DEPOSIT AT SUNTRUST BANK Savings Account Certificate of Deposit ON DEPOSIT AT HERITAGE SOUTH COMMUNITY CREDIT UNION Certificate of Deposit Earnings on CD ON DEPOSIT AT WELLS FARGO ADVISORS (formerly WACHOVIA) (Market Value in Portfolio $25,828 @ 6130112) Certificate of Deposit Certificate of Deposit ON DEPOSIT AT RAYMOND JAMES FINANCIAL SERVICES (Market Value in Portfolio $57,646 at 6/29/12) Total - June 30,20 12 Submitted by: D. Michael Costello, Treasurer 1 100 Tallan Financial Center Chattanooga, Tennessee 37402 423 756-7 100 800-782-8382 mikecostello@decosimo.com