Oconomowoc Rotary Membership Application. By completing this application you acknowledge that you understand Rotary policies regarding dues, attendance and participation in club activities.
Questions marked by * are required.
1. Insert Title or Prefix (Dr., Rev., Hon., etc. if used)
2. First Name or Initial: *
3. Middle Name or Initial:
4. Last Name: *
5. Insert Suffix (Jr., CLU, M.D., Ph.D.; etc.) if used:
6. Call Name or Nickname ( Bob, Liz, etc. - this is the name that we put above your full name on the Rortary member badge): *
7. Birthday (mm/dd/yyyy - only day and month will be displayed)
8. Preferred Email (for newsletter and announcements): *
9. Secondary email, if any (newsletter and announcements will be sent to this address also)
10. Name of Rotary Sponsor or Contact:
11. Are you a current or former member of a Rotary Club? *
  • No
  • Yes
12. If Yes to above, please insert name of club:
13. Committees or Activities in whiich you have an interest (check all that apply):
  • Club Service (Socials, Fundraisers, Golf Outing, etc.)
  • Community Service (Bingo, Highway Cleanup, Independence Day Parade, etc.)
  • International Service (International Youth Projects, Student Exchange, Rotary Foundation, etc.)
  • Vocational Service (Career Development, Vocational Presentations, etc.)
14. Home Address (street);
15. Additional Home Address:
16. Home Address city:
17. Home Address State (WI, IL, etc.):
18. Home Address Zip Code:
19. Home Phone (including area code):
20. Mobile Phone:
21. Business Name:
22. Business Address:
23. Additonal Business Address:
24. Business Address City:
25. Business Address State (WI, IL, etc.):
26. Business Address ZIP code:
27. Business Phone (including area code):
28. Business Fax (including area code):
29. Business URL (if you want it listed in the directory):
30. Job Title/Position *
31. Spouse/Partner First Name or Initial:
32. Spouse/Partner Middle Name or Initial:
33. Spouse/Partner Last Name:
34. Spouse/Partner Insert Suffix (Jr., CLU, M.D., Ph.D.; etc.) if used:
35. Spouse/Partner Call Name or Nickname (Bob, Liz, etc.)
36. Spouse/Partner Birthday (mm/dd/yyyy - only day and month will be displayed)
37. I certify that I am qualified for membership both by my current/former executive positions and by having a place of business or residence within the club's locality or surrounding area. I understand it will be my duty, if accepted, to exemplify the Object of Rotary in all my daily contacts and activities. I agree to pay a new member fee of $50.00 and quarterly dues and meals fee of $190.00 per quarter. (Does not apply to secondary or corporate members.) I grant permission to the club to publish my name and proposed classification in all membership information. *
  • Yes
  • No