ZONTA District 4 NOMINATION FORM for candidates to serve during the 2020-2022 biennium
PRIVACY STATEMENT The information you supply on this Nomination Form will be used to assess your suitability for the stated position you are seeking. If you do not provide complete and accurate information, your nomination is likely to be disregarded. Your Nomination Form will be destroyed following the District No information will be disclosed to third parties without your authorization, except if required by law.
Position/s nominated for:
District Board Nominating Committee ☐ Governor ☐ ☐ Lt. Governor ☐ Treasurer ☐ Area Director
Section 1 To be completed by Nominee – Personal Information
First Name: Click here to enter text.
Last Name: Click here to enter text.
Mailing Address: Click here to enter text. .
Most available Phone Number (including country code): Click here to enter text.
Email Address: Click here to enter text.
Skype Address: Click here to enter text.
Photo supplied as described on page 5 at the bottom
Supply a in 250 Bio words or less, that can be used in the conference program Click here to enter text.
Section 2 Zonta Membership Information
Zonta Club of: Click here to enter text.
Country: Click here to enter text. District: Click here to enter text.
Number of years of Zonta membership: Click here to enter text.
Classification Number and Description: Click here to enter text.
Click here to enter text.
2.1 District Involvement
District offices held
a) Appointed (including dates): Click here to enter text.
Page 2 of 5
b) Elected (including dates): Click here to enter text.
Number of district conferences attended: Click here to enter text.
Year and location of last three (3) attended: Click here to enter text.
2.2 Club Involvement
Club offices held:
a) Appointed (including dates): Click here to enter text.
b) Elected (including dates): Click here to enter text.
2.3 Your Achievements within Zonta (maximum 150 words):
Click here to enter text.
Section 3 Business/Professional Information – provide your most recent information
Current Company/Organization: Click here to enter text.
Nature of business (maximum 10 words): Click here to enter text.
Position/Title: Click here to enter text.
Number of years in most recent position: Click here to enter text.
Responsibilities of position (maximum 50 words): Click here to enter text.
Describe how your business or professional experience and skills will contribute to the position for which you are submitting your nomination (maximum 100 words):
Click here to enter text.
Section 4 Involvement in other organizations
Involvement with civic, community or professional organizations, positions held in the last five years and any future commitments (maximum 100 words):
Click here to enter text. Page 3 of 5
Section 5 5.1 Questions for nominees for Officers (Governor, Lt. Governor, Treasurer and Area Directors).
a. What are your goals for advancing the objects of Zonta International and how do you propose to accomplish them? (maximum 100 words):
Click here to enter text.
b. What special competencies and attributes, do you possess which qualify you to serve in the position(s) for which you have been nominated? (maximum 50 words):
Click here to enter text.
5.2 Question for nominees for Nominating Committee
Please describe your understanding of succession planning for future Zonta leaders and how you will identify, engage and recruit candidates (maximum 200 words):
Click here to enter text.
Section 6
Risk Questions
Zontians are individuals who are working together to change the lives of women and are known for being honest and trustworthy. The ones elected for the top leadership positions hold and handle funds in trust for our members and our projects.
As with many other not for profit organizations, our success relies in the trust of our stakeholders. This trust has to be continuously maintained by the commitment of all members, but particularly at leadership positions, with the highest ethical principles. If only one donor or stakeholder loses confidence in Zonta, it would be one too many. If Zonta’s reputation is damaged, it will be very difficult to repair.
To contribute to the accountability and transparency of our future top leaders, please answer the following questions:
1. Have you during the last 5 years been convicted or found guilty by a Court of any offense in any country (excluding parking or motoring offences)? Choose an item: ___Yes ___No
If Yes please explain. Click here to enter text.
2. Have you during the last 5 years been put on probation in a legal sense or is there any action pending against you? Choose an item: ___Yes ___No
If Yes please explain. Click here to enter text.
3. Have you ever been denied entry into the United States of America?
Choose an item: ___Yes ___No
If Yes please explain. Click here to enter text. Page 4 of 5
Section 7
Signatories to Nomination
Note that in the following section there are one signature required for the Nomination Form to be accepted:
1. Nominee – must be a Zonta club member in good standing1
The nominator must complete the information at Section 8 b).
Please note that electronic signatures are acceptable. Alternatively, the pages may be downloaded, signed, scanned and emailed by the due date.
The signed nomination form shall be sent via email to [email protected] by midnight on March 31st, 2019.
1 Definition of “good standing” is given in the Glossary of the Zonta International Governing Documents, 2016
Confirmation of Zonta information:
Please provide the contact details of a Zonta member (may also be the nominator) who can confirm that your Zonta information in this form is correct.
First name: Click here to enter text.
Last name: Click here to enter text.
Most available phone number (including country code): Click here to enter text.
Email address: Click here to enter text.
Skype Address: Click here to enter text.
Zonta Club of: Click here to enter text. Page 5 of 5
Section 8
a) Nominee’s Declaration
I, Click here to enter text. consent to have my name submitted for consideration for the positions(s) of:
Click here to enter text.
I confirm that:
I understand the duties, responsibilities and time commitment of the role(s) for which I am being nominated.
The information provided in this Nomination Form and in any supporting document is accurate and correct and no significant information has been omitted.
I understand that any incorrect, misleading or omitted information may disqualify me from office.
I agree to be interviewed, and any incorrect information may disqualify me from office.
I pledge that:
I have read and will abide by the Zonta District 4 Campaigning Policy available at ___________________________________
I will uphold and abide by the Bylaws and Rules of Procedure of Zonta District 4.
If elected, I will carry out the duties and responsibilities of the stated position and conduct myself in an appropriate manner.
If, due to unforeseen circumstances, I become unable to run for the stated position, I undertake to notify the Nominating Committee Chairman immediately.
I authorize the Zonta District 4 Nominating Committee to contact the individual, who I nominated as my referee for the purposes of my application.
Nominee’s signature: Date: Click here to enter text. X
b). To be completed by Nominator
First name: Click here to enter text.
Last name: Click here to enter text.
Nominator’s signature Date: Click here to enter text. (or President if a club) X
In order for your submission to be complete the Nominee must email this completed form and a 600dpi (minimum 300dpi) photograph to the Nominating Committee at to [email protected] by midnight on June 1st, 2019.
