Membership Application Form

Name and Title

Name *

Nickname for Badge *

Title or Position *

Business Contact

Business Name

Business E-mail

Business Phone

Business Address

Country

Address 1 *

Address 2

City *

State *

ZIP code *

Home Contact

Cell Phone

Home E-mail

Home Phone

Home Address

Country

Address 1 *

Address 2

City *

State *

ZIP code *

Detailed Info

Primary Contact Preference *

Date of Birth *

Month

Day

Year

Life Partner/Spouse Name

My Profession/Field of Work

I am a former Rotarian. The Club and date of membership were

Dues and Agreements

I am paying the required initiation fee of $300 with this application. Click here to pay application fee

Once inducted into the Club, I understand that I will be obligated to pay dues, prorated for the month in which I join. Dues are invoiced semi-anually. Upon induction, I consent to publication of my name, photo and brief bio on the Club's website and social media sites.

Signature

Use your mouse or finger to provide a signature in the box below

Signer Name *

Signer Title *

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