MEMBERSHIP APPLICATION
PO Box 909, Hot Springs, AR 71902 hsnprotaryclub@gmail.com
Personal Information:
Full Name
*
Dr.
Mr.
Miss
Mrs.
Ms.
Prefix
First Name
Middle Name
Last Name
Suffix
Birthdate
*
-
Month
-
Day
Year
Gender
*
Please Select
Male
Female
Marital Status
*
Single
Married
Other
Spouse/Significant Other Name
Dr.
Mr.
Mrs.
Ms.
Prefix
First Name
Middle Name
Last Name
Suffix
Spouse/Significant Other Birthdate
-
Month
-
Day
Year
Anniversary
-
Month
-
Day
Year
Do you have a child(ren)?
*
Please Select
Yes
No
Child(ren) Information
Rows
Child(ren) Name
Gender
Birthdate
1
2
3
4
5
Home Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Home Phone Number
Format: (000) 000-0000.
Mobile Phone Number
*
Format: (000) 000-0000.
Work Phone Number
Format: (000) 000-0000.
Personal E-mail
*
example@example.com
Work E-mail
example@example.com
Preferred Email to use for communications
*
Personal
Work
Name of HSNP Rotary Member Sponsoring You
*
Why are you interested in joining our Rotary Club?
*
What organizations are you currently involved in and in what ways do you serve (ie. Volunteer roles, community organizations, family activities, leadership positions held, etc.)?
*
Personal Hobbies & Interests
*
Have you ever been convicted of a felony?
*
Please Select
Yes
No
Provide Date(s) and Details Regarding Felony Conviction:
Business Information:
Company Name
*
Occupation/Job Title
*
Work Address
Street Address
Street Address Line 2
City
State
Zip Code
Company Website
Are you a past member of a Rotary Club?
*
No
Yes
Name of Club, Location, and Rotary ID Number
Rotary Club Achievements (ie.: offices held & date of service)
Other Information for Membership Consideration
I hereby affirm that all information provided in this application is true and complete to the best of my knowledge. I understand that any false or misleading information may result in the denial or termination of my Rotary membership. I further acknowledge that all applicants may be subject to background checks in accordance with Rotary Club policies, especially for involvement in programs that serve youth or vulnerable populations. I consent to such checks if required. By signing below, I confirm my understanding of and agreement to the commitments, responsibilities, and expectations of Rotary membership.
*
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