New Member Application
Date
-
Month
-
Day
Year
Date
Potential Member Name
First Name
Last Name
Current or Former place of Employment?
Classification (ie: Insurance, Education, Financial Management)
Work Email
example@example.com
Personal Email
example@example.com
Which Email is preferred for Rotary Communication?
Work
Personal
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Personal Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Which Phone Number is preferred?
Work
Personal
Work Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Which address would you like the Rotary Magazine to be delivered to?
Work
Personal
Membership Type, please select one.
Active (one individual - full membership dues)
Active - Corporate (up to 5 people on one membership, one active the rest honorary)
Honorary (other people on Active - Corporate Membership, other than lead person)
Who referred you to the Rotary Club of Schaumburg/Hoffman Estates?
First Name
Last Name
Why do you want to join the Rotary Club of Schaumburg/Hoffman Estates?
Have you been a Rotarian at another club before? If yes, please list below. If no, please leave blank and skip to the next question.
Submit
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