Red = Required
Name and Middle Initial on Passport                                                                    Go-By First Name

                 
Business: Address                                                                                   Phone                                  Fax

              
Home: Address                                                                                 Phone                                  Preferred email

For (check one):  active     honorary membership

If a former Rotarian, list club(s) and dates:

Rotary Recognition(s): Paul Harris Fellow   Rotary Foundation Benefactor  

Proposed classification:

Name of firm and executive position (former firm and executive position, if retired):

Activities which would enhance consideration as a Rotarian:

Rotarian proposing new member:   Email:

Statement to be agreed by proposed member after Club's Board has approved proposal

I hereby certify that I am qualified for membership both by the current/former executive position and by having a place of business or residence within the club's territorial limits, adjoining territory, or the same city in which the club is located.

I understand that it will be my duty if elected, to exemplify the Object of Rotary in all my daily contacts and activities and to abide by the constitutional documents of Rotary International and the club. I agree to pay an admission fee of $50.00 and the annual dues of $832.00 in accordance with the bylaws of the club. I hereby give permission to the club to publish my name and proposed classification to its membership.

Information for club directory:

        
Cell Phone                         Web Site                                                                                  Proposed Member's Birthday

 
Hobbies

Short biography telling how proposed member developed to current profession (Examples: Beck, Morris, Wayne):

         
Partner's Name (Spouse or significant other)                                       Partner's Birthday                              Wedding Anniversary