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Rotary Club of Greensboro Membership Application
Membership Application
Applicant Name
*
First
Middle
Last
Preferred Name/Nickname
*
Who is the Rotary Club Member proposing you for membership?
*
First
Last
Date of Birth
*
MM slash DD slash YYYY
Email
*
Home Phone
Cell Phone
Business Phone
Occupation/Job Title
*
Business/Organization Name
*
Preferred mailing address
*
Residential
Business
Postal Box
Residential Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Business Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Postal Box Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Family Information
Spouse/Significant Other Name
First
Last
Are you married?
*
Yes
No
Anniversary Date
MM slash DD slash YYYY
Number of Children
Number of Grandchildren
Education
School name and degree
School name and degree
School name and degree
Military Service
Have you served in the military?
*
Yes
No
Branch
Length of service (in years)
Rank
Previous Rotary Clubs
Have you been a member of another Rotary Club?
*
Yes
No
Rotary ID Number
Name of Club
City
State
--select state--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Date Joined
MM slash DD slash YYYY
Date Resigned
MM slash DD slash YYYY
Have you been a member of a second Rotary Club?
*
Yes
No
Name of Additional Club
City
State
--select state--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Date Joined
MM slash DD slash YYYY
Date Resigned
MM slash DD slash YYYY
Have you been a member of a third Rotary Club?
*
Yes
No
Name of Club
City
State
--select state--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Date Joined
MM slash DD slash YYYY
Date Resigned
MM slash DD slash YYYY
Community Activities
Rotary's motto is "Service Above Self." Please tell us about any community and volunteer activities you have been or are currently involved in.
Community / Volunteer Activities
Hobbies / Talents / Skills / Interests
References
Please list two other Rotary members willing to serve as references.
Name
First
Last
Name
First
Last
Rotary Club of Greensboro is involved in many activities and depends on its members to volunteer. In which of these might you be interested? Check as many as you wish.
Community Service Projects
Project Rebuild - Access ramps for low-income
Salvation Army Kettle Bell Ringing
Rotary Youth Leadership Camp
PigStock - BBQ competition to support charity
Tutoring at Sumner Elementary School
Food Insecurity Projects
International Service
Rotary Foundation
World Community Service
Youth Exchange
End Polio Now
Global Grants and Scholars
Club Service
Fellowship/Greeters
Registration Table
Fundraising
Public Image - Social Media
Sergeant-at-Arms - Club meeting setup
Membership Recruitment
New Member Orientation
Membership Engagement
Social and Networking Events Planning
Service Project Coordination
Donations Committee - Grant Appliications Review
I am submitting this application for membership to the Rotary Club of Greensboro. All information is accurate to the best of my knowledge. I have read and understand the
Proposed New Member Outline
(Guidelines and Responsibilities) and
Financial Responsibilities
provided to me.
Signature
*
By typing my name above, I affirm that the above information is accurate to the best of my knowledge.
Today's Date
*
MM slash DD slash YYYY
Date
MM slash DD slash YYYY
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