The following Membership Application Form is to be completed by a Rotarian who wishes to propose an individual for membership in the Mystic Rotary Club

Mystic Rotary Club

New Member Information Form

(To be completed by proposer and returned to the Club Secretary and Club Classification Officer.)

I am proposing for Club membership:

Name (First, Middle, Last):

Nick Name

Home Address:

Home phone number:

Email Address:

Current (or former) business name / profession and your position:

Business Address:

Business phone number:

Your birth date:

Spouse or companion's name:

Wedding anniversary date:

If transferring or former Rotarian, list previous Club information:

Club:
Membership dates:
Membership Type: ? Active ? Honorary
Paul Harris Fellow: ' Yes ' No
Recent Transfer (one year or less) ? Yes ? No

Proposed Classification-This application:

If an RI program participant or foundation alumnus, list program (s) and date (s):

Past/Current activities & experiences that would enhance candidate's consideration

as a Rotarian:

Please give additional information about yourself on the reverse side of this application:

Early background. ? Education; College, Degrees. ? Family. ? Other

Proposer's Signature: Date:

Rev. 1-10-2009