Membership Proposal

Your Title (required)

Family Name (required)

First Names (required)

Known as (required)

Gender (required)
---MaleFemale

Date of Birth [dd/mm/yyyy] (required)

Spouse/Partners name

Spouse/Partner Date of Birth [dd/mm]

Anniversary Date [dd/mm] :

Preferred language (required)

Are you a Rotarian now/have you previously been a Rotarian : (required)

If yes, RI membership ID number if known

Name of current or former club

Date originally joined Rotary [dd/mm/yyyy]

Have you had any former Involvement in Rotary programmes such as Interact, Rotaract; Youth Exchange and if ‘yes’ please elaborate:

Current firm or if retired Former firm

Position

Residence Address

Business Address

Home Phone Number

Business Phone Number

Mobile Phone Number

Fax

Your Email (required)

Where should we mail you?
---ResidenceBusiness

Alternate address (complete only if mailing address is a P.O. Box)
---ResidenceBusinessOther

The Magazine that your membership requires you to subscribe to is Rotary Africa. Please state whether you would prefer a PRINTED or DIGITAL magazine (*)
---PrintedDigital

Do have access to the Internet for personal use?
---YesNo

Please tell us about any special skills that you have that you would like to share with us?

Please tell us about any activity that you are involved in which could be of benefit to any of Rotary’s programmes?

Name of your Proposer