Rotary Club of Jeffersonville, Indiana
Applicant Certification

(This section is to be completed by applicant, upon approval of proposal by board, having been informed of privileges and responsibilities of Rotary membership)

I hereby certify that I am personally and actively engaged in the business or profession or professional activity covered by the classification that has been proposed for me and that my place of business or residence is located within the territorial limits of the club or within the corporate limits of the city in which the club is located or within an immediately adjoining territory.

I understand that it will be my duty, if elected, to exemplify the Object of Rotary in all my daily contacts and activities, and to abide by the constitution and bylaws of the club. I understand that part of my membership dues will provide me an annual subscription to the official magazine or an approved and prescribed regional magazine as may be applicable. I agree to pay the admission fee of $    ____   and the annual dues of $  ____     in accordance with the bylaws of the club. I hereby give permission to the club to publish my name and proposed classification to its members.

Date               Applicant's signature

Record of action on proposal

Date proposal received by secretary

Date submitted to the board

Board decision

Date proposer notified

Date Rotary information session was held

Date signed card and remittance was received

Date membership was published to membership

Date the new member was inducted