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West Ventura County Rotary Membership Application
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Email
*
Your email
Membership Category
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Individual
Corporate
Family
Honorary
Candidate’s First Name:
*
Your answer
Candidate’s Last Name:
*
Your answer
Gender:
*
Your answer
Nickname
*
Your answer
Candidate Section:
Work/Home Address:
*
Your answer
City
*
Your answer
State:
*
Your answer
Zip:
*
Your answer
Phone:
*
Your answer
Cell:
Your answer
Company Name:
Your answer
Years Employed:
Your answer
Or Community Leadership Role:
Your answer
Preferred Phone Contact:
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Home/Cell Phone
Work Phone
How long have you been a resident of the Ventura area?
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Your answer
Years in the area?
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Your answer
Have you been a Rotarian before?
*
Yes
No
If yes, please provide the following:
Club Name:
Your answer
Dates of Membership:
Your answer
Classification Held:
Your answer
Paul Harris Fellow:
Yes
No
Clear selection
Rotary Membership Number:
Your answer
Sustaining Member:
Yes
No
Clear selection
Former Club Contact Information:
Your answer
Offices held and responsibilities:
Your answer
Spouse / Partner name, if applicable:
Your answer
Birthday:
*
MM
/
DD
/
YYYY
Summary of education and / or background:
Your answer
Potential areas of interest in Rotary:
Your answer
Areas of skills you want to offer to the club:
Your answer
Past or current community projects, memberships or boards:
Your answer
Applicant’s signature (please type your name)
*
Your answer
A copy of your responses will be emailed to the address you provided.
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