Membership Proposal – Lake Chelan Rotary

Application Date*
MM slash DD slash YYYY
Name of Rotarian Sponsoring Applicant:
First Last
Sponsoring Rotarian Email
Enter Email Confirm Email
Name of Proposed Member*
First Last
What is Applicants Birthdate*
MM slash DD slash YYYY
Is Proposed Member Retired?*
Name of Spouse or Partner
First Last
What is Applicants Anniversary Date
MM slash DD slash YYYY
Applicants Email Address:*
Enter Email Confirm Email
Name of Proposed Members Business:
Proposed Members Mailing Address*
Street Address Address Line 2 City State ZIP Code
Proposed Members Physical Address:*
Street Address Address Line 2 City State ZIP Code
Applicants Home Phone Number:*
Applicants Business Phone Number:*
Applicants Mobile Telephone Number:*
Is Applicant a Former Rotarian*
Rotary Membership Number
Is Applicant an Active Rotarian at Another Club*
Is Applicant Transferring from Another Club*
Name of Club
From:
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
Is Applicant A "Paul Harris Fellow":*
Members Classification:*
Ativities that would enhance consideration as a Rotarian:*
0 of 500 max characters
Why do you want to be a Rotarian?*
Email
This field is for validation purposes and should be left unchanged.