Rotary Club Membership Proposal Form Part A

Rotary Club Membership Proposal Form – Part A

Part A (to be completed & returned to the club secretary/president) (MS Word is preferred response format.)

I propose:

Title (Mr., Mrs. Ms., Miss, Dr): ______

Full name: ______

Mailing address: ______

Telephone #s (including area codes)

Residence: ______

Business: ______

Cellular/Other: ______

Fax: ______

Preferred e-mail address: ______

Preferred e-mail address is (check one): ___ Residence ___ Business

Proposed classification (business type): ______

If rejoining or a former Rotarian, list most recent club information:

Previous club name: ______Previous Club # ______

Previous Rotary membership ID: ______

Dates: From ______To ______

Recent Rotarian (in past year): ___Yes ___No

If an RI program participant or Foundation alumnus/a, list program(s) and date(s):

______

Activities that would enhance consideration as a Rotarian (for example, what community services person is/has been involved in and plans to be involved in, and if person would be able to help with club fundraising, membership, golf tournament, etc.):

Why candidate would like to join Rockville Rotary:

Proposer’s (sponsor) Signature ______Date ______

Rotary Club Membership Proposal Form – Part B

(Part B to be completed by proposed member after approval)

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, and by having a place of business or residence within the club’s locality or surrounding area.

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 annual dues in accordance with the club

bylaws. I hereby give permission to the club to publish my name and proposed classification, if applicable, to

its membership.

Proposed Member’s Signature ______

Date ______