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

I propose:


Name



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