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New Rotarian Info Request
This form is used to gather information from prospective members. Once complete, the information is
given to Dr. Bob Cassidy to start the two-week approval and induction process. For member responsibilities
and expectations, please find the Become a Member link on our website,
www.LHArotary.com
.
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* Indicates required question
I would like to join the Rotary Club of
*
Lake Houston Area
Summer Creek
Club Sponsor
*
Your answer
First Name
*
Your answer
Middle Name or Initial
*
Your answer
Last Name
*
Your answer
Home Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
Mobile Phone (digits only no spaces ex: 9999999999)
*
Your answer
Home Phone (digits only no spaces ex: 9999999999)
Your answer
Email Address
*
Your answer
Alternate Email Address (for billing)
Your answer
Birthday
*
MM
/
DD
/
YYYY
Spouse Name
Your answer
Wedding Anniversary
MM
/
DD
/
YYYY
Classification/Industry
*
Your answer
Company/Business Name
*
Your answer
Business Address
*
Your answer
City
*
Your answer
State
*
Your answer
Business Zip Code
*
Your answer
Business Phone (digits only no spaces ex: 9999999999)
*
Your answer
Website
Your answer
Preferred Phone
*
Business
Home
Cell
Other:
Preferred Address
*
Home
Work
Other:
Dues and Billing Preferred Email
*
Primary Email
Alternate Email
Other:
$100 Initiation Fee
*
Bill to you
Paid
Active Rotarian at this time? (for Rotary Transfers)
*
Yes
No
Date Joined (for Rotary Transfers)
MM
/
DD
/
YYYY
Paul Harris Fellow? (for Rotary Transfers)
Yes
No
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