District Committee Interest Form

Nebraska-Iowa District

Circle K International

Name:		Email:
Club:		Year in School:

Street Address:

City:

State:

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Zip:

Primary Phone:

Secondary Phone:

Circle K / Leadership Experience

Years in Circle K:

1

2

3

4

5

Other

Current position held:
Member
Club Officer

Previous leadership positions held (not limited to Circle K):

Coordinator Position Desired:

Please list the position(s) you are most interested in:
Club Resource Committee
Public Relations Committee
Would you be willing to be a Chair for your Committee:	Yes No

Please use the space provided to briefly describe why you should be considered for a coordinator position. How can you contribute to the success of the district board? If you are interested in a specific coordinator position, what ideas do you have in mind for that position?

Thank you for your interest!!

Click the Submit button to send your completed form to the Circle K District Governor and Administrator. Forms must be submitted no later than May 1st, 2008 to be considered. Appointments will be made in May.