Name and Middle Initial on Passport*

Go-By First Name*

Business: Address

Business: Phone

Business: Fax

Home: Address*

Home: Phone*

Preferred email

For (check one): active honorary membership

If a former Rotarian, list club(s) and dates:

Rotary Recognition(s): Paul Harris Fellow Rotary Foundation Benefactor

Proposed classification:

Name of firm and executive position (former firm and executive position, if retired):*

Activities which would enhance consideration as a Rotarian:

Rotarian proposing new member:*

         Email:*

Statement to be agreed by proposed member after Club's Board has approved proposal

I hereby certify that I am qualified for membership both by the current/former executive position and by having a place of business or residence within the club's territorial limits, adjoining territory, or the same city in which the club is located.

I understand that it will be my duty if elected, 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 an admission fee of $25.00 and the annual dues and meals of $500.00 in accordance with the bylaws of the club. I also understand that all members are encouraged to contribute a minimum of $100.00 per year to the Rotary Foundation. I hereby give permission to the club to publish my name and proposed classification to its membership.

Information for club directory:

Member: Cell Phone

Member: Web Site

Member: Birthday

Hobbies

Short biography telling how proposed member developed to current profession:

Partner's Name (Spouse or significant other)

Partner's Birthday

Wedding Anniversary