Southtowne Membership Application - Eugene Southtowne Rotary

Personal Information

Full Name *

First

Middle

Last

Nickname

Birthday *

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Preferred Email *

Phone (Home)

Phone (Cell) *

Spouse / Significant Other's Name & Occupation

Children's Name(s)

Professional Information

Occupation *

Classification

Business / Organization *

Position / Title *

Business Address *

Address Line 1

Address Line 2

City

State

Zip Code

Business Email *

Phone (Work)

Phone (Cell) *

Previous Rotary

Club Interests

Club Name

Membership Start Date

Membership End Date

Positions Held

Hobbies / Other

Paragraph Text

I understand that it will be my duty, if elected, to serve on a Rotary committee, attend its meetings and engage in its activities. I agree to pay the admission fee of $100 with my application and dues of $140 every six months. I give my permission to the Club to publish my name and information to its membership.

Signature *

Clear Signature

Proposer's Name