Rotary Club of Jeffersonville, Indiana
Membership Proposal and Application-Front

I propose:


Business address                            Business telephone/fax

Residence address                            Residence telephone/fax

for (check one):     active        additional active        past service        senior active membership

If a former Rotarian, list club(s) and dates

If affiliated with a firm:

Name of firm                            Position

Principal and recognized activity of firm

Principal and recognized activity of candidate, if different from that of employer or if independently engaged in a profession

If retired, position and employer or profession at time of retirement

Activities which would enhance consideration as a Rotarian:

Date                            Proposer's signature