Good Sam International Chapter of the Year Nomination

Name of Chapter_____________________________________________________________

Location of Chapter__________________________________________________________

Number of Rigs____________________Year Chartered_____________________________

Name of person nominating Chapter____________________________________________

Name of Chapter President____________________________________________________

Below are some of the Good Sam International projects in which your chapter might have participated this past year. Please check off all the applicable projects for the chapter. For each one checked, kindly include specific information on how many chapter members participated, where the activity was held, how often throughout the year and how much money was raised (Dogs for the Deaf). If you have received any media publicity, please include that info or attach a copy of the article. You may use another sheet of paper if more space is needed.

Adopt-A-Highway:

National Cleanup:

Dogs for the Deaf:

What has this chapter done this past year to increase its membership?________________

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What has this chapter done this year to help support your State/Provincial Samborees?

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The chapter being nominated has most likely participated in many other activities, such as in local community services, at health or hospice facilities, senior centers, homeless/battered victim shelters, orphanages, camps, schools, or with fraternal organizations, animal shelters, youth groups, charities, just to name a few. Please use another sheet of paper to tell us what else the chapter has done this past year. Include information on what the project was about, how many members participated, is it an on going project or just a one time event, what was the project’s goal, how many man-hours were spent on the project this year, did the chapter received public recognition and if so, in what way. If the event was a fundraiser, please tell us how much the chapter raised or what financial impact of their efforts was. Although photos or newspaper articles are not mandatory, if some are available, please include copies with this form.

Also please include any other reasons why this chapter should be the Good Sam International Chapter of the Year.

Your signature_____________________________________Date_____________________