I propose:

Name:                           

Business Address:   

Residence  Address: 

Home Telephone:       

Business Telephone: 

   for (Check one)                active                           honorary membership

 If a former Rotarian, lists clubs and dates:

Proposed classification: (If active or additional active):

Name of Firm and executive position (former firm and executive  position if retired:

Name and phone numbers of at least three other Rotarians who know the proposed member and who may be contacted confidentially:

(1)

(2)

(3)

How long have you know the proposed member?

Activities which would enhance consideration as a Rotarian:

Proposer's Name and  Date: