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Membership Application

Membership Application

Name *

First

Last

Date of Birth *

Email *

Mobile *

Home Telephone

Home address

Address Line 1

Address Line 2

City

State

Zip Code

Name of Spouse / Partner

First

Last

Business Contact Information

Business / Employer Name

Position Title or Description

Business Telephone

Business Address

Address Line 1

Address Line 2

City

State

Zip Code

Tell us why you'll make a great Rotarian

Background

Please provide some vocational and personal background detailed that will enhance your activities as a Rotarian

Proposed Classification

This will be printed on your Rotary name badge

Requested Membership Type

Individual
Corporate

If not sure, choose “individual”

Previous Rotary Club Memberships

Please indicate locations and years of membership

Signature

Please enter your full name

Please enter today's date

Name