Application – West Salem Rotary Club

Name (person applying for membership)*

Full name of proposed member candidate, First, Mid, Last
Title, professional certifications, etc

Professional certifications (MD, CPA, JD, PhD, etc)
Date of Birth

Date of birth needed so Rotary can calculate profiles of club demographics. The year will not be made public.
Applying for (check one)*
- Active member
- Retired member
- Transfer from another club
If transferring, name of previous Rotary Club affiliation
Residence Address*

Address of proposed member (Street, Apt, etc)
City*
State*
Zip Code*
Email, applicant*

Best email to reach you
Phone*

Best phone to reach you
Business or Organization*

Name of business, organization, etc (where you work)
Occupation or principal activity*

List your occupation, work title, etc
Work Address*

Work address of proposed member (Street, Apt, etc)
City (work address)*
State (work address)*
Zip Code (work address)*
Phone (work)*

Best phone to reach you
If retired, occupation or principal activity at time of retirement

List your occupation, work title, etc while you were working
Community or professional activities, brief resume
List activities, professional affiliations that would enhance consideration as a Rotarian.
Name of Rotarian proposing member

Name of current Rotarian proposing member candidate
Date of application*