Ventura South Rotary Membership Application
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Email *
Membership Category *
Candidate’s First Name: *
Candidate’s Last Name: *
Gender: *
Nickname *
Candidate Section:
Work/Home Address: *
City *
State: *
Zip: *
Phone: *
Company Name:
Years Employed:
Or Community Leadership Role:
Preferred Phone Contact: *
How long have you been a resident of the Ventura area? *
Years in the area? *
Have you been a Rotarian before? *
If yes, please provide the following:
Club Name:
Dates of Membership:
Classification Held:
Paul Harris Fellow:
Clear selection
Rotary Membership Number:  
Sustaining Member:
Clear selection
Former Club Contact Information:
Offices held and responsibilities:
Spouse / Partner name, if applicable:
Birthday: *
Summary of education and / or background:
Potential areas of interest in Rotary:
Areas of skills you want to offer to the club:
Past or current community projects, memberships or boards:
Applicant’s signature (please type your name) *
A copy of your responses will be emailed to the address you provided.
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