Western Henrico Rotary
Membership Application

Please fill out the application form below, and a club representative will contact you shortly.
Use the TAB Key -or- click the MOUSE to move to new fields

Your Information:
Your Full Name:
Nick Name:
E-Mail Address:


(Receipt Confirmation sent here)

 
Employer Information: Name:
Position:
Description of
Business:
Years with Employer :
Business Address - Street :
City, State ZIP:
Business Phone :
Business FAX:
Previous Employers:

Home Address - Street :
City, State ZIP:
Home Phone:
Cell Phone:
Preferred Address
for Rotary Mail:



Years in Richmond:
Place of Birth:
Date of Birth:
Other Places of Residence:
Hobbies/Interests:
Foreign Languages Spoken:
Musical Instruments Played:

 
Colleges Attended / Degrees:

 
Spouse's Full Name:
Spouse's Hometown:
Childrens Name and Ages:

 
Former Rotarian?
 
 


Former Rotary Club Name and Location:
Offices Held:
Civic or Fraternal Organizations:
Professional Organizations:
Social Organizations:
Name of Rotarian submitting your name:

I understand I am applying for membership in Western Henrico Rotary Club, which is affiliated with Rotary International. Western Henrico is one of more than 32,000 Rotary clubs worldwide with over 1.2 million Rotarians. To be a member, I understand I will be expected to attend meetings on a regular basis, and if I miss a meeting, I will be expected to make-up at another Rotary club. I also agree to participate in club activities and promptly pay dues and fees.
Signed by: