Report of Voting Delegates – Civitan Clubs inside North America

Select Your Club Name from Dropdown List Below:*
Person Completing Form (Club Presidents Only)*

*This form should only be completed by Club Presidents, if for some reason that is not possible, contact priscilla@civitan.org before moving forward.
As Club President, I certify that the following items have been accomplished or completed by my club: (CLICK ALL THAT APPLY)*
- All financial obligations have been met on the International and District levels. This includes: International Dues, annual insurance assessment from International, District Dues, Candy Box payments.
- My club’s roster/member information is updated with Civitan International.
- At least one current governance document (Constitution, Articles or Bylaws) is in place to guide my club’s actions.
- My club has filed the required 990 with the Internal Revenue Service for the 2020-2021 year (American clubs only) OR has submitted any annual filings as required by a governmental agency (Canadian clubs).
On behalf of my club, I acknowledge that Civitan International is the owner of its licensed mark(s) seen below, and the name and brand of Civitan and Junior Civitan, and all use of the licensed mark/brand will solely be to the benefit of Civitan International and its mission. My club agrees that it shall not take any action to dilute the brand/mark or tarnish its reputation, obtain any registration of it independently, nor use it outside the realms of Civitan International’s mission.*
- I agree