| 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)
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| 2. |
First Name or Initial: *
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| 3. |
Middle Name or Initial:
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| 4. |
Last Name: *
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| 5. |
Insert Suffix (Jr., CLU, M.D., Ph.D.; etc.) if used:
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| 6. |
Call Name or Nickname ( Bob, Liz, etc. - this is the name that we put above your full name on the Rortary member badge): *
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| 7. |
Birthday (mm/dd/yyyy - only day and month will be displayed)
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| 8. |
Preferred Email (for newsletter and announcements): *
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| 9. |
Secondary email, if any (newsletter and announcements will be sent to this address also)
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| 10. |
Name of Rotary Sponsor or Contact:
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| 11. |
Are you a current or former member of a Rotary Club? *
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| 12. |
If Yes to above, please insert name of club:
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| 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.)
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| 14. |
Home Address (street);
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| 15. |
Additional Home Address:
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| 16. |
Home Address city:
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| 17. |
Home Address State (WI, IL, etc.):
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| 18. |
Home Address Zip Code:
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| 19. |
Home Phone (including area code):
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| 20. |
Mobile Phone:
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| 21. |
Business Name:
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| 22. |
Business Address:
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| 23. |
Additonal Business Address:
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| 24. |
Business Address City:
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| 25. |
Business Address State (WI, IL, etc.):
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| 26. |
Business Address ZIP code:
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| 27. |
Business Phone (including area code):
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| 28. |
Business Fax (including area code):
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| 29. |
Business URL (if you want it listed in the directory):
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| 30. |
Job Title/Position *
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| 31. |
Spouse/Partner First Name or Initial:
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| 32. |
Spouse/Partner Middle Name or Initial:
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| 33. |
Spouse/Partner Last Name:
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| 34. |
Spouse/Partner Insert Suffix (Jr., CLU, M.D., Ph.D.; etc.) if used:
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| 35. |
Spouse/Partner Call Name or Nickname (Bob, Liz, etc.)
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| 36. |
Spouse/Partner Birthday (mm/dd/yyyy - only day and month will be displayed)
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| 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. *
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