Georgia Kiwanis New Club Charter Member Online Processing Portal
Please complete the following information.
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Mobile Phone Number
Please enter a valid phone number.
Spouse/Partner Name
Date of Birth
*
-
Month
-
Day
Year
Date
Business Information
Business Name
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Phone
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Which Address do you want your Kiwanis Mail to be sent?
*
Please Select
Home
Business
Do you have a nickname you wish to include with your membership application? If so please list it below.
Verification Information
Do you hereby agree to accept this application for membership and agree to conform to the bylaws of this club and comply with the obligations of membership as explained to me by my sponsor?
*
Please Select
Yes
No
Which new Kiwanis club are you joining as a charter member?
*
Please write the name of the Kiwanian who is sponsoring you for membership?
*
Which type of club membership are you applying for?
*
Please Select
Regular
Corporate
My Products
*
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New Charter Membership Fee
$
160.00
Credit Card
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