Rotary Club Membership Application Form

INDIVIDUAL Membership Application
Complete the form below to apply to membership in our Rotary Club.

Who is your Rotarian sponsor or reference?

Name

First NameLast Name

Home E-mail

example@example.com

Work E-mail

example@example.com

Home Phone Number:

Work Phone Number:

Mobile Phone Number:

Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Work Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Send Rotary Correspondences to

WorkHome

Birth Date:

MonthDayYear

Why are you interested in joining our Rotary Club?

Describe your past involvement with the community and service?

Are you a past member of a Rotary Club?

YesNo

If yes, name of club and location:

Are you a past participant in a Rotary International or Rotary Foundation program?

YesNo

If yes, which program and when?

Are you applying for a Corporate Membership?

YesNo

If yes, please provide names, titles and emails of other associates who will represent your organization.

Please confirm that you understand the privileges and responsibilities associated with Rotary membership, and agree to promote the ideals of Rotary and comply with the requirements of the Rotary Club.

YesNo

Once you submit your application, we will contact you shortly to complete your membership application.

Thank you!