Wakefield Rotary Membership Application

Membership Application
Date

MonthDayYear
Date
Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Phone Number
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Occupation(Previous, if not currently working)
Employer
Gender
Birthday (including year)

MonthDayYear
Date
Spouse’s name (if applicable)
Wedding Anniversary date (if applicable)

MonthDayYear
Date
Referred by (Rotarian’s name)
Current or previous Rotary Club
Previous Years in Rotary
Rotary # (if applicable)
Membership Type

Active Individual Membership--$45/month, $150 one-time initiation feeActive corporate membership-- $60/month, $200 one-time initiation feeActive individual social membership-- $25/month, $50 one-time initiation fee
Please Upload Headshot Picture

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Signature

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After Submitting your application, along with a Headshot Picture your with your application will be reviewed by the Board of Directors and a decision will be made in 30 days or less. If you have any questions feel free to email:membershipchair@wakefieldrotarync.com
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