E-club of District 5870 Membership Proposal Form
to be completed by proposed member
Full Name
Your answer
Home Address
Your answer
Phone Number (Cell)
Your answer
Phone Number (Home)
Your answer
Phone Number (Business)
Your answer
Email Address
Your answer
Occupation (if retired, former occupation)
Your answer
If transferring clubs or a former Rotarian, list most recent club information (name, years of service, previous Rotary member ID)
Your answer
If a Rotary International participant or Foundation alumnus, list program(s) and date(s):
Your answer
Activities that would enhance consideration for your Rotary membership:
Your answer
If not being proposed by a current Rotarian, please list two personal references and their contact information.
Your answer
Interests Inventory: Let us know your interests so we can get you connected with club committees and activities. (check all that apply)
I hereby certify that I am qualified for active membership by my current or former status as a business, professional, or community leader, or as a Rotary Foundation alumnus/a. I understand that, if accepted for membership, it will be my duty to exemplify the Object of Rotary in all my daily contacts and activities and to abide by the constitutional documents of Rotary International and the club. I agree to pay any admission fees required by the club and to pay quarterly dues in accordance with the club bylaws. I hereby give permission to the club to publish my name and proposed classification to its membership. ( please type name and date to certify)
Your answer
Looking forward to serving with you! #powerup4service
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