Rotary E-Club Membership Application Form

Membership Application

Complete the form below to apply to membership in our Rotary Club.
Date

MonthDayYear
Date
Name*

First NameMiddle NameLast Name
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
example@example.com
Phone Number:*

Area CodePhone Number
Birth Date:*

MonthDayYear
Spouse Birth Date:

MonthDayYear
Anniversary (if applicable) :

MonthDayYear
What is your Current Occupation?*
Areas of Interest:

EnvironmentFoundationSocialPublic ImageFundraisingDiversityInternationalMembershipCommunity ServiceYouth/EducationWebsite
Are you a past or current member of a Rotary Club?*

YesNo
If yes, name of club and location:
Previous or Current Rotary Membership ID:
Are you a past or current participant in the Rotary Foundation?*

YesNo
If yes, what Paul Harris Level?
Who is your Rotarian sponsor or reference?
Why are you interested in joining our Rotary Club?
By submitting this application, indicates that I understand:

My application will be circulated among Board members and club members for a vote on my application for membership and I recognize that my application may be rejected for whatever reason deemed appropriate by the organization.

If accepted into membership, it will be my duty to exemplify the objectives of Rotary in all my daily contacts and activities, and to abide by the constitutional documents of Rotary International and the E-Club. I agree to pay dues annually or semiannually in accordance with club bylaws. I hereby give permission to the club to publish my name and proposed application to the club membership.
Please attach a Headshot photo before submitting the application.

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