Seattle Rotaract Membership Application

Name                           

    Family Name                                        First                                                         Middle

Date of Birth                 

Home Address              

Office Address              

Telephone/

Fax Numbers                

E-mail Address             

Occupational

Classification/

Area of Study               

Areas of Interest

o Community Service

o International Service

o Professional Development

o Youth Service

o Club Service

1. Will you take part in 60% of the club’s social and service activities?     o Yes        o No

2. Are you willing to pay member dues ($25 annually)?         o Yes      o No

I understand and accept the principles of Rotaract as expressed in its purpose and objectives

and agree to comply with and be bound by the Standard Rotaract Club Constitution,

Rotaract Statement of Policy, and bylaws of the club.

Signature                     

Date                            

The Seattle Rotaract club secretary will retain this form for club records.