Club Officer Report Form 2022-2023 | Civitan International

Please submit new officers following election. List the current mailing address, telephone contact numbers (with area code), and email address(es) for each officer.

Click here to download a PDF version of this form. If you choose to complete the form using the PDF version, please mail a copy to Civitan International World Headquarters and your District Governor. You may also email to WHQ at growth@civitan.org.

Report of Civitan Club Officers 2022-2023

Club Officers for 2022-23 (term beginning October 1, 2022)

Your Name*
First Last
Your Email*
Civitan Club Name*
President Name
First Last
President Email
President Phone
President Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
President-Elect Name
First Last
President-Elect Email
President-Elect Phone
President-Elect Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Secretary Name
First Last
Secretary Email
Secretary Phone
Secretary Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Treasurer Name
First Last
Treasurer Email
Treasurer Phone
Treasurer Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
International Dues Billing Statements should be mailed to:*
- Club Treasurer
- Club Secretary
- Club President
- Club PERMANENT Address (entered at bottom of this form)
- Other
If you chose "other" above, enter the club billing contact's name, address, email and phone here:
Public Relations Chair
First Last
Public Relations Email
Social Media Chair Name
First Last
Social Media Chair Email
Webmaster Name
First Last
Webmaster Email
Candy Box Chair Name
First Last
Candy Box Chair Email
Candy Box Chair Phone
Candy Box Chair Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Coin Box Chair Name
First Last
Coin Box Chair Email
Coin Box Chair Phone
Coin Box Chair Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Does the club have a PERMANENT club mailing address? (Physical clubhouse, P.O. Box, etc.,)? If so, enter the permanent club address here.
This should NOT be a member’s personal address.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

After clicking submit, you should receive an email notification that includes all of the information you provided in this form. If you do not receive the confirmation email in a timely manner, please check your spam and junk folders. If you are having trouble, please email growth@civitan.org.