Distinguished Member Award

Name of Person Completing this form.

First Last

Your Email

Are you submitting this form for yourself or someone else?

Myself

Another member of my club

Name of Person who is being nominated.

First Last

Email of Person who is being nominated

Name of First New Kiwanian

Name of Second New Kiwanian

Name of first Project

Date of first project

Name of second Project

Date of second project

What Conventions did this person attend?

District Convention

Regional Convention

International Convention

Select all that apply.

Kids Need Kiwanis