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Milpitas Rotary Membership Form
Thank you for signing up to become a member. The information provided on this form will not be shared or disclosed to anyone else other than the Rotary Club of Milpitas.
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Name
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Nickname
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Date of Birth
MM
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DD
/
YYYY
Email Address
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Residential Address
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City
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Zipcode
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Home Phone
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Cell Phone
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Business Name
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Job Title
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Business Phone
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Business Address
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City (Business)
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Zipcode (Business)
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Significant Other's Name
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Significant Other's Birthday
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Married
Yes
No
Anniversary Date
MM
/
DD
/
YYYY
Previous Rotary Club Name
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Start Date with the previous club
MM
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DD
/
YYYY
End Date with the previous club
MM
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DD
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YYYY
End Date with the previous club
MM
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DD
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YYYY
Club Achievements
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