Milpitas Rotary Membership Form
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Name
Nickname
Date of Birth
MM
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DD
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YYYY
Email Address
Residential Address
City
Zipcode
Home Phone
Cell Phone
Business Name
Job Title
Business Phone
Business Address
City (Business)
Zipcode (Business)
Significant Other's Name
Significant Other's Birthday
Married
Anniversary Date
MM
/
DD
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YYYY
Previous Rotary Club Name
Start Date with the previous club
MM
/
DD
/
YYYY
End Date with the previous club
MM
/
DD
/
YYYY
End Date with the previous club
MM
/
DD
/
YYYY
Club Achievements
Submit
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