ROTARY MEMBERSHIP APPLICATION

ROTARY MEMBERSHIP APPLICATION
Potential members are asked to complete the following information. Starred items(* are required.

After completing this form, click 'Submit' and the Club you are requesting to join will receive your application. You can also print this form and mail it per your Club's instructions. A copy of this application will be emailed to you.
Title
First Name *
MI
Last Name *

Suffix:
Last Name *
Nickname
Birthdate *

Month Day Year
Date
Gender *
Email *
example@example.com
Home Phone
Cell Phone
Sponsor(s)

Home
Sponsor 1 *
Sponsor 2
Please check the

below next to your preferred mailing address
Address 1
Address 2
(Ste/Suite)
Address 3
City
State
County
Postal Code
Company
Position
(Business Position / Job Title)
Business

Business
Website
Office Phone
Fax Number
Address 2
Address 1
Address

Address 3

Street Address Line 2

City
State
County
Postal Code
https://www.dacdb.com/SecLogin3.cfm
First Name

MI Name:
First Name
Last Name

Suffix:
Last Name
Nickname
Date of Birth

Month Day Year
Date
Married

No (mm/dd/yyyy) No Rotary ID Number:
Is Spouse/Partner a Rotarian?:
Club#
Club Name
City
State
Date Joined

Month Day Year
Date
Date Resigned

Month Day Year
Date
Previous Club EMail
example@example.com
Club#
Club Name
City
State
Date Joined

Month Day Year
Date
Date Resigned

Month Day Year
Date
Previous Club EMail
example@example.com
CLUB PARTICIPATION / ACHIEVEMENTS: i.e., offices held in club and which year.
BIO / DESCRIPTION: i.e., personal and professional background
DEGREES
HOBBIES & INTERESTS: i.e., golf, fishing, and hunting
HOBBIES & INTERESTS: i.e., golf, fishing, and
COMMUNITY LEADERSHIP & OTHER COMMENTS: i.e., community organizations you are involved with (board member, volunteer, etc), projects, organizations, subjects you

could give a 30 minute talk on to the club.

https://www.dacdb.com/SecLogin3.cfm
Should be Empty:

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