| Full Name:
First, last, and middle |
required |
| Family Name |
required |
| Call name:
(nickname) i.e. "Bill" "Jane" |
required |
| Email: |
required |
| Confirm Email: |
required |
| Highest Rotary
Office: |
|
| Rotary
Classification: |
|
|
Name of Rotary Club:
|
(Rotary-Rotaract,
etc.) |
|
Rotary District #: |
|
|
Zone #: |
|
| Mailing
Address: |
|
| City: |
|
| State,
Postal Code, Country: |
|
| Home Phone: |
|
| Work Phone: |
|
| Cell Phone:
|
|
|
Spouse / Partner Name |
|
|
If your Spouse / Partner is a Rotarian,
please list their club |
|
|
Areas of interest in service
to Rotary (one selection is required) |
required |
|
Club Web Site URL
|
http://
|
|
District Web Site URL
|
http://
|
|
Is your district history online?: |
required
I would like to be considered as my district's Official RGHF
District Historian. Details at
www.districthistory.org |
| Rotary Awards: |
|
| Rotary
Activities: |
|
|
RENEWAL FEE
One option must be selected
from this list * |
Please choose
one option below:
|
|
$ 30.00 USD |
1 YR NEW MEMBER FEE |
|
|
$120.00 USD |
5 YR NEW MEMBER FEE |
|
|
CONTRIBUTE TO THE FELLOWSHIP:
|
Valid Amount: $100 -
$10,000
The Fellowship invites
interested individuals, clubs, and districts to
make a contribution that will support the work
of the fellowship. Any contribution of $100 USD or
more will be listed at
our
Major Contributors page. |
|
Additional Comments |
|
|
|
DISCLAIMER Please note that Fellowship
membership dues are paid on
an annual basis and due on July 1 of
each year. Individuals who
become members after July 1 are required
to pay the full annual fee
as dues are not pro-rated based on the
time of year an individual
becomes a member. All payments are
immediately applied to the
work of the Fellowship. No refunds or
pro-ration of dues will be made
once payment is submitted or upon
cancellation of membership. Check here that you agree with
our disclaimer
* required |