Ashburn Rotary Member Application
Club Members: Please use this form to propose an individual for club membership.

Membership Questions: Please e-mail Doug Corbett - doug@dougcorbettvoice.com
Technical Questions: Please e-mail Adam Benware - adambenware@gmail.com

Proposed Member Name
This is the name of the individual being proposed for membership
Your answer
Club Member Name
This is the name of the sponsoring Club Member
Your answer
Address
This is the residential address of the proposed member
Your answer
Spouse Name
This is the name of the spouse of the proposed member
Your answer
Business Affiliation
This is the name of the proposed member's business/organization
Your answer
Activity of Firm
This is a description of the proposed member's business/organization activity/field
Your answer
Phone Number
This is the preferred phone number of the proposed member
Your answer
Position
This is title of the of proposed member's title at their business/organization
Your answer
Business Address
This is the address of the proposed member's business/organization
Your answer
Membership Type
This is the membership type for which the proposed member is being submitted
Current or Former Rotary Affiliations
If applicable: Description of proposed member's Rotary affiliations. Please include club name(s) and dates.
Your answer
Proposed Classification
Please provide a description of the proposed member's classification (for Active, Additional Active, or Family membership types)
Your answer
Activities
List activities that would enhance proposed member's consideration as a Rotarian
Your answer
Proposed Member Email Address
Your answer
Name of Submitter
Your answer
Submit
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