New Member Form – Rotary Passport to Service Club

Title

Name *First
Last

Suffix

GenderMale
Female

Birthdate (MM/DD/YEAR)

Are you a former Rotarian or a current member of another Rotary club?No
Yes

If yes, RI membership ID number

Name of former/current clubCurrent members should not officially terminate their membership in their current clubs. Their changes will be recorded when Rotary admits the new club.

Are you a Rotary alumnus/alumnae?No
Yes
Alumni are former participants of Interact, Rotaract, Youth Exchange, RYLA, Rotary Peace Fellowships, Rotary Scholarships, vocational training teams, and Group Study Exchange.

Email *

Preferred PhonePlease include area code; if other than North America, please include country & city code

Alternate Phone

Preferred mailing address (check one):Residence
Business
Other

AddressAddress Line 1
Address Line 2
City
State / Province / Region
Postal Code
Country

Alternate address (complete only if mailing address is a P.O. box):Residence
Business
Other

Address Line 1

Address Line 2

City

State

Zip Code

Magazine — Select one:The Rotarian (print)
The Rotarian (digital)
Rotary Regional Magazine

For use in verification of compliance with Rotary policy:

Job Title:

Name of your business or organization

Classification