Membership Proposal Form
To be completed by proposer
Title *
Name *
First and last name
DOB *
MM
/
DD
/
YYYY
Mailing Address *
Primary Phone *
Business Phone
Preferred Email Address *
Proposed Classification (occupation) *
If rejoining or a former Rotarian, list most recent club information:
Previous club name and dates:
Activities that would enhance consideration:
Proposer's Name *
First and last name
Submit
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