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.