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:*

Format: (000) 000-0000.

Work Phone Number:*

Format: (000) 000-0000.

Mobile Phone Number:*

Format: (000) 000-0000.

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!