New Member Form

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Mystic Rotary Club

Perspective Member Application Form

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:                                                                       

If transferring from a Rotary Club 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

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

Past and or current professional, business, volunteer, or community leadership activities

& experiences that you believe would benefit our club and serve you well as a Rotarian:

Please give the following additional information about yourself on a separate sheet and send it in

with this application:

• Early background. ? Education. ? Family. ? Other

Applicants Signature:                                                                 Date:                          

March 2011