Member application

Applicant

Name(Required)

First Middle Last

Email(Required)

Preferred Name:

Home Address:

Street Address Address Line 2 City State ZIP Code

Cell:

Age:

Years in Baton Rouge:

Spouse:

Spouse's Phone:

Educational Background

College:

Degree Awarded:

Noteworthy leadership roles/awards:

Business

Name of business/organization:

Business Email address:

Business Address:

Street Address Address Line 2 City State ZIP Code

Business phone:

Position/Title:

Years in this industry:

Years with this business:

Describe your position in the business:

Describe your business:

Is at least 60% of your time devoted to this business activity?

Yes

Are you retired?

Yes

Date retired

Rotary Background

Are you a former Rotarian?

Yes

If so, list each former club, dates of membership and offices or committee positions held:

Please include all relevant information regarding your activities in both the community and your profession. List activities, dates of membership, leadership positions, achievements and any awards received.

Community/Civic/Religious Activities

Organization/agency:

List offices held and committees chaired:

Business and Professional Service and Activities/Associations

Name of association:

List leadership positions(s), committee activities and any other relevant information:

Signature(Required)

Printed name(Required)

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