RI Dist. 3170 Name of DG: Rtn. Dr. Jorson Fernandes
Add: “Villa
Shanti Niketan”, Mokim, Cuncolim, Salcete, Goa , India – 403703
Tel:
0832-2763347 / 2733334, Mob: 09822101334 E-Mail: drjorsonferns@gmail.com
District
Governor’s Official Club Visit Memo Format
-2 Page 1 of 12
Name of the Club: _________________________________Date of
Visit: ________________________
Name of Asst. Governor:
_________________________________________
1)
President and Secretary’s Meeting:-
Designation
|
Name & address, Tel Nos., E-Mail
|
Signature
|
President of the Club 2012-13
|
Name:___________________________________________
Address:__________________________________________
_________________________________________________
_________________________________________________
Tel. Nos:_________________________________________
Mob:___________________________________________
E-Mail:__________________________________________
|
|
Secretary of the Club 2012-13
|
Name:___________________________________________
Address:__________________________________________
_________________________________________________
_________________________________________________
Tel. Nos:_________________________________________
Mob:___________________________________________
E-Mail:__________________________________________
|
|
President of the Club 2013-14
|
Name:___________________________________________
Address:__________________________________________
_________________________________________________
_________________________________________________
Tel. Nos:_________________________________________
Mob:___________________________________________
E-Mail:__________________________________________
|
|
Secretary of the Club 2013-14
|
Name:___________________________________________
Address:__________________________________________
_________________________________________________
_________________________________________________
Tel. Nos:_________________________________________
Mob:___________________________________________
E-Mail:__________________________________________
|
|
Treasurer of the Club 2012-13
|
Name:___________________________________________
Address:__________________________________________
_________________________________________________
_________________________________________________
Tel. Nos:_________________________________________
Mob:___________________________________________
E-Mail:__________________________________________
|
|
Asst. Governor
|
Name:___________________________________________
|
|
Special Invitee if any (GSR/Mentor)
|
Name:___________________________________________
Address:__________________________________________
_________________________________________________
_________________________________________________
Tel. Nos:_________________________________________
Mob:___________________________________________
E-Mail:__________________________________________
|
|
Club Service:- Page 3 of 12
a)Communications from District and to the District: Excellent / Good/ satisfactory
Any
suggestions: _______________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
b)Club Charter Date _____________________________ Charter No:
__________________
c)Charter Day / Nite celebration date: _________________
d)Name of Historian of the Club: ________________________________
E-Mail:___________________
e)Club Bulletin Name: ___________________________(Weekly/Monthly/Quarterly/Yearly)
f)Club Assemblies Conducted for
2012-13 dates: ______________, ________________, _____________,
________________, ________________, ______________.
g)BOD Meetings conducted for 2012
-13 dates: __________________, ______________, ____________,
___________, ______________,
_______________, ____________, ___________, ____________
h)Strategic Planning Meeting of
Club held on :___________________, Minutes maintained: Yes/No
Strategic Plan of the Club reviewed
on :_______________
Compliance Report if not done by ______________(Date)
DCC Strategic Plan of the region marked the action to assist the club with
concerned AG
i)Club Action Book maintained Yes
/ No, updated by historian on : __________________
j)Member Access registered by the
President: Yes / No
Compliance Report: if not done then DCC
New Technology and AG to assist by ______________(Date)
k)Annual Gen. Body Election
Meeting of the Club fixed on/ held on _________________(date)
l)Information to world HQrtrs
through Member access to upload information of President and secretary for the
world directory done on
__________________(Date)
m) Check list of documents to be
made available for the DG’s Visit:
S.No.
|
Checklist for President’s and Secretary’s Meet
|
Available
|
Not available
|
Compliance Action marked to:
|
01
|
Club Charter
|
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02
|
Manual of Procedure
|
|
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03
|
RI Directory (Book / DVD)
|
|
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04
|
Club Constitution and ByLaws adopted on _______
|
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05
|
President’s
and secretary’s work book manual filled
|
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06
|
a)Audited Acts of 2011-12/ previous years file
maintained
b)Annual budget for 2012-13 / Annual budget file maintained
|
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07
|
Classification roaster updated on _____________
|
|
|
|
08
|
List of PHFs, RFSMs
Updated position of balances
List of major donors
|
|
|
|
09
|
Name list of
prospective PHFs, RFSMs and major donors
|
|
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10
|
B.O.D. Minutes book
|
|
|
|
11
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Club
Assembly Minute Book
|
|
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12
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Weekly Meeting Minute Book
|
|
|
|
13
|
Attendance Register for weekly meetings
|
|
|
|
14
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Special
Mailing List of Club maintained
|
|
|
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15
|
Visitors’
Book maintained for events
|
|
|
|
16
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a)List and addresses of Club Members with Tel. Nos.
and e-mail IDs
b) List of Dist. Officers from the Club
|
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17
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Strategic Planning File
|
|
|
|
18
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Planning Guide for effective Clubs duly filled and signed by President, secretary and AG
|
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19
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Membership Goal form
|
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20
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TRF Goal form
|
|
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21
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Club Plans & Objectives for 2012-13
|
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22
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Club Committee Plans
CLP Committees
Avenues wise Sub Committees
|
|
|
|
23
|
Information on Permanent projects
|
|
|
|
24
|
Copies of SAR-1 sent on _________ for ______Mem
Copies of SAR-2 sent on _________for ______Mem
Fees to Rotary News sent on _______ for ____ mem
Fees towards Dist. Fund sent on ______for ___mem
|
|
|
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25
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Club Publication file maintained
|
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26
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TRF Annual giving file maintained
|
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|
27
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Matching grant file maintained
|
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|
28
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Club dues file maintained
SAR file maintained
Rotary news dues paid file maintained
Dist. Fund dues paid file maintained
|
|
|
|
29
|
a)Club
action Book maintained
b)Club Membership Register / Roaster(could be part of Club action Book)
c)Awards received
by the Club
|
|
|
|
30
|
a)Trust Deed
b)Names of
Trustees:
|
|
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Page
4 of 12
Administration:- Page
5 of 12
a) Membership details:
* Membership less than25 / more than25
New Member Information kit given /
not given
Orientation of new members conducted on ____________(date)
Membership
|
Numbers
|
Membership Goal of RI and District met with:
|
Compliance report action marked to: DCC MDR of the
region.
|
Membership as on 1-7-12
|
|
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Members added
|
|
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Members resigned
|
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Members terminated
|
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Total number of members as on date
|
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Honorary members
|
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Membership dues sent to RI for
|
|
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b)Financial obligations of new members :
_______ New members, RI dues paid
by ______ members, Subscription to “The Rotarian by ____members,to Rotary
News/Rotary Samachar by _____members, Dist. Fund paid by _____ members towards
TRF paid by ______ members
c)Financial obligations of
members:
No. of members
|
Amt. per Rotarian
|
Paid to
|
Balance to be paid
|
Back log of RI dues
|
Back log of RNT dues
|
Compliance report by:
|
|
|
RI 1st. half
2nd half
|
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Rotary News trust
|
|
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Dist. Fund
|
|
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d)Attendance for weekly Meetings on an average is ________
compliance action marked to: ____________________________________
Meetings to be interesting to members:_____________________________________________
e) Partners –in-service
Associations
|
No. of Clubs
|
Membership strength
|
Address and Tel Nos. of
President
|
Compliance report if any by:
|
Interact
|
|
|
|
|
Rotaract
|
|
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|
|
RCC
|
|
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Innerwheel
|
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Rotakid
|
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Probus Clubs(Optional)
|
|
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f)Dist. And Revenue
Dist. Events organized/ Hosted:
Sr. No
|
Name of the event
|
Organised on (Date), event Chairman name:
|
01
|
|
Date:
Name of event Chairman:
|
02
|
|
Date:
Name of event Chairman:
|
03
|
|
Date:
Name of event Chairman:
|
04
|
|
Date:
Name of event Chairman:
|
g)Effective Club:-
S. No
|
Criteria for effective Club
|
complied with
|
Compliance report
|
01
|
Directors for 5 avenues of service appointed
|
Yes / No
New Generation service
Director appointed
|
|
02
|
Club Leadership Plan adopted on(date)
|
Date:
Memb. Dev. Comm. Chair:____________________
Club PR Chair:______________________________
Club Adm. Chair:____________________________
Service Projects Chair:________________________
TRF Chair: _________________________________
|
|
03
|
Sustained membership
|
|
|
04
|
Increase in membership by 3%
|
Complied for ______ members
|
|
05
|
Implemented service project to meet needs of Community
|
Name of the project:_______________________
________________________________________
Conducted on:________________________
|
|
06
|
Support TRF
|
Contributions:______________________
Participation:______________________________
_________________________________________
|
|
07
|
Leaders beyond Club level
|
Number: ________
|
|
Page 6 of 12
h)Training:- page
7 of 12
Programme
|
Date
|
Members / Youth
|
Beneficiaries reaction
|
RYLA conducted
|
|
|
|
RYLA attended
|
|
|
|
R.L.I attended
|
|
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TOTS attended
|
|
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Club L-Ship Prog attended
|
|
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Dist. L-Ship Prog attended
|
|
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Speech Craft attended
|
|
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3R Rotary – Wochardt Prog
|
|
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Triage Officer Prog. On Disaster mgmt.
|
|
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Rotary Institute
|
|
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Pre-PETS
|
|
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PETS & SETS
|
|
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|
Dist. Assembly
|
|
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DTTTS
|
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AGTS
|
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Memb. Dev. Seminar
|
|
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Polio Plus Planning Workshop
|
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TRF Seminar
|
|
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|
Vocational Service:-
a)Vocational Awards:-
(Three Outstanding Persons)
1. Outstanding Women Entrepreneur:
______________________________________________
2. Outstanding Differently -abled Entrepreneur:
________________________________________
3. Outstanding Sports
personality:_________________________________________
b) Career
Awareness Programme conducted on ________ date for ____no. of
beneficiaries
c)Supported the career
awareness VDO by identifying Institutions from the region:-
Name and Address of the Institution
|
Contact
Person Tel Nos.
|
Faculty available
|
|
|
|
|
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d) Earn while you
learn programme introduced in _______ (Number)organizations having ______
vacancies, for ________ beneficiaries.
e) Four Way Test
promoted to _________________ no. of beneficiaries.
Four Way Test
|
Institution / Community
|
No. of beneficiaries
|
Hoarding
|
|
|
Book Time
tables
|
|
|
Book Labels
|
|
|
Book Covers
|
|
|
Umbrellas
with 4-Way test
|
|
|
T-Shirts
|
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|
Meetings
|
|
|
|
|
|
|
|
|
Community
Service:-
Projects
|
Date
|
No. of Beneficiaries
|
TB Control Prog.
|
|
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Maternal
& Child Health
|
|
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Adult
Education
|
|
|
Computer Literacy
|
|
|
Vocational
Training
|
|
|
Water and
sanitation
|
|
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Community
Development
|
|
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Project for Sp. Children
|
|
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Blood
Donation
|
|
|
Environmental
Protection
|
|
|
Projects
with RCC
|
|
|
Projects
with Rotaract
|
|
|
Project with
Interact
|
|
|
Project with
Innerwheel
|
|
|
Project with
Rota Kid
|
|
|
Project with
Probus Club
|
|
|
Project on
Disease Prev. & Control
|
|
|
Peace
Conference conducted
|
|
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Peace
Conference attended
|
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Page 8 of 12
Page 9 of 12
International
Service
1. The
Rotary Foundation:-
a)Polio Immunisation
promotional activities
Promotional activity
|
Conducted on (date) quantum of
people reached
|
NID 1st
|
|
NID 2nd
|
|
Polio Road Show
|
|
Media awareness
Radio
Print Media
Mass Media
|
|
Lectures
|
|
Routine Immunisation booth maintained at
__________________________________
|
Routine immunisations conducted on ___________
____________ reaching ____
Community on an average
|
Any other activity
|
|
b)Group Study
Exchange
Incoming team
hosted by ___________________________________ (Name of the member)
Outgoing team :Team
member sponsored : _________________________________________
Team Leader sponsored : ___________________________________
c)TRF Contributions:
TRF Goal for the year 2012-13: _____________________________________________
To:
|
Amount in $ / INR
|
Compliance Report by ______
|
Annual Giving
|
|
|
Permanent Fund
|
|
|
Major Gifts
|
|
|
Bequest society
|
|
|
Benefactor
|
|
|
Paul Harris Society
|
|
|
Matching Grants
|
|
|
EREY
|
|
|
RFSM
|
|
|
Rotary Foundation Coupons
|
|
|
PHF / Multiple PHF
|
|
|
d)Matching Grants Ongoing Project: page
10 of 12
MG Project NO:
|
|
Action marked to for compliance
|
Action marked to for compliance at Dist. level
|
Partner
|
|
|
|
Project Cost
|
|
|
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Status
|
|
|
|
Contact Primary
|
|
|
|
Contact Secondary
|
|
|
|
Interim Report sent on
|
|
|
|
Likely closure of the project by (Date)
|
|
|
|
Any suggestions or help from District:
______________________________________________________
_____________________________________________________________________________________
e) Matching Grant
Completed: (Previous year / Present Year)
File closure / Final report sent on ______________________ due on _____________
date
Closure letter from TRF received on _____________________
due on _______________date.
f) Matching Grant
(New Project)
Nature / Type: _____________________________________________________
Purpose/ Objectives:
___________________________________________________________________
__________________________________________________________________________________
Project Cost: _________________________Club Contribution:
___________________________
DDF from 3170: _______________ DDF from partrner Dist: No: ________ of
____________(amount)
Partner contribution: _____________, Any other:
___________________________
g)Dist. Simplified Grant:Obtained previously then give
details: _________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Compliance completed / due on ______________
Details of New Project: ______________________________________________________
2)Dist. Conference and Convention
to Lisbon
Registrations
|
Dist. Conference
|
RI Convention to Lisbon
|
Single
|
|
|
Couple
|
|
|
Children
|
|
|
Page 11 of 12
3)Int. Youth Exchange: Programme
conducted for _______ members
4) Int. Fly. Exchange Programme
conducted for _____ members to
___________RI Dist.
5) Disaster Mgmt. support to _______ Club /
______ Dist. By _____ Volunteers / _______amount. Sent on ________.
New Generation Service
Name of the Project
|
No. of beneficiaries
|
Compliance action marked to
|
RYLA
|
|
|
Youth Dev. Project
|
|
|
Talent Search
|
|
|
Quiz
|
|
|
Skill Dev. Prog.
|
|
|
|
|
|
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|
Presidential Citation Criteria:-
Criteria
|
Complied with
|
Non-Compliant
|
Action marked to:-
|
*EREY by 31-3-2013
|
|
|
|
*Net increase by 1 member
|
|
|
|
*85% min. retention
|
|
|
|
2% increase in qualified women membership
|
|
|
|
2% increase in qualified professionals (<45 yrs. Of age)
|
|
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|
Induction of 1 or more TRF Alumni
|
|
|
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Increased diversity
|
|
|
|
“*” marked
are mandatory points, from the remaining 4 we must comply with 2.
Rotary Public Image:
PR Event
|
No. of people reached
|
No. of Institutions reached
|
New members sought in the Club
|
Compliance report
|
Orator of Dist. 3170
|
|
|
|
|
Rotary Wockhardt 3R Prog
|
|
|
|
|
R.I. PR Grant prpoject (Rotary
Week)
|
|
|
|
|
Any other project
|
|
|
|
|
Awards:-
Page 12 of 12
Award
|
Nominee
|
Deadline to RI
|
Nominators
|
Name of Nominee
|
|
RI Presidential Citation
|
Rotary Club / DG
|
15th. Apr. 2013
|
DG 2012-13
|
|
|
Significant Achievement Award
|
Rotary Club
|
15th. March 2013
|
-do-
|
|
|
4-Avenues Citation award
|
Active Rotarian
|
15th. Feb. 2012
|
2012-13 Club Presidents
|
|
|
Rotary Award for world understanding and Peace
|
Non-Rotarian/ Non Rotary
Organisation
|
1st. Nov. 2012
|
Any ActiveRotarian
|
|
|
Award for Rotary Foundation Alumnii
|
Rot. Foundation Alumnii
|
|
DG 2012-13
|
|
|
Awards won by the
Club:-
Year
|
Name of the Dist. award
|
|
|
|
|
|
|
|
|
Club Assembly
Name
|
Designation
|
Signature with date
|
|
President 2012-13
|
|
|
Secretary 2012-13
|
|
|
Asst. Governor 2012-13
|
|
Rtn. Dr. Jorson Fernandes
|
Dist. Governor 2012-13
|
|