Membership Expression of Interest – Rotary E-Club Serving Humanity

To express your interest in becoming a member of the Rotary E-Club Serving Humanity please complete and submit the form below:

Name *

First

Middle

Last

Please complete all sections marked with a red asterisk before the form will SUBMIT

Gender *

Languages spoken *

List any Honours or Qualifications to your name

Are you a Rotarian or former Rotarian? *

If yes, what is your RI Identification Number

Are you a retired from work? *

What is your current or former work position? *

Name of employer or former employer

Work address

Your email address *

Confirm Email

Your home phone number

Your mobile phone number *

Your Date of Birth *

dd/mm/yyyy

Home address *

Postal address *

Spouse's Name *

First

Last

Enter "No Spouse" if single

Date of your Wedding Anniversary

dd/mm/yyyy

Choose your magazine subscription - Digital is cheaper *

If you want hard copy we may have to charge you more than digital which included in your dues.

Phone