Application for Membership

Apply for Membership with The Rotary E-Club of District 7545
(a.k.a. The Mountain State Rotary E-Club)

Please fill out this form as completely as possible. Submission of this application requests approval for Membership to The Rotary E-Club of District 7545 – the Mountain State Rotary E-Club. Your submission of this application authorizes us to do the following with all, an excerpt of, or a summary of, the information you submit on this application:

to contact references provided by you; and/or
to have your name submitted to the E-Club Board of Directors (or the organizing committee for such) for review and action; and/or
to circulate information about you to our E-Club membership for comment, as required by Rotary International; and/or
to contact your previous Rotary Club(s) to verify your current/previous standing in Rotary (if applicable)

Personal Information

First Name
Last Name
Home Address
Address 2
City
State
Country
Zip/Postal Code
Email Address
Time Zone
Home Phone
Home Fax
Mobile Phone
Birthday (mm/dd/yyyy)

Other Electronic Contact Information

Yahoo
MSN
ICQ
AIM
Skype
Google Talk

Business Information

Company
Title
Website
Business Phone
Business Fax
Address
Address 2
City
State
Country
Zip/Postal Code

Present/Former Rotarian Information (if applicable)

Most Recent Rotary Club
Club Secretary's Email
Rotary ID Number
When did you join Rotary? mm/dd/yyyy
Classification
If you were, but are no longer a member of a Rotary Club, what was the reason for your departure from Active Membership?

References

Please identify a Rotarian who can serve as a reference to your service and involvement as a current/former Rotarian:

Name
Email
Phone

Please identify someone who can serve as an additional reference:

Name
Email
Phone