Membership application

Rotary E-Club Membership Application

Date ______________

Full Name _____________________________________

Mailing Address ______________________________________________________________

Preferred Email __________________________________

Phone Contact ____________________

Date of Birth _____________   Anniversary (if applicable) ___________  Spouse ___________

Current Occupation ____________________________________________________________

Areas of Interest:

Environment __          International __

Foundation __            Membership __

Social __            Community Service __

Public Image __            Youth/Education __

Fundraising __            Website __

Diversity __            Youth/Education __

If Past Rotarian:

Club or clubs__________________________________________________________________

Areas of Service _______________________________________________________________

Paul Harris level __________        Previous Rotary Membership ID _________________

I understand, that 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.

Signature ____________________________        Date ______________

Please send the application to ____________________ via mail or email:


Please enclose a photo with the application.


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