Rotary Club of Jeffersonville, Indiana
Applicant Certification
(This section is to be completed by applicant, upon approval of proposal by board,
having been informed of privileges and responsibilities of Rotary membership)
I hereby certify that I am personally and actively engaged in the business or profession or professional activity covered by the classification that has been proposed for
me and that my place of business or residence is located within the territorial limits of the club or within the corporate limits of the city in which the club is located or within an immediately adjoining territory.
I understand that it will be my duty, if elected, to exemplify the Object of Rotary
in all my daily contacts and activities, and to abide by the constitution and
bylaws of the club. I understand that part of my membership dues will provide
me an annual subscription to the official magazine or an approved and prescribed
regional magazine as may be applicable. I agree to pay the admission fee of $ ____ and
the annual dues of $ ____ in accordance
with the bylaws of the club. I hereby give permission to the club to publish my
name and proposed classification to its members.
Date Applicant's signature
Record of action on proposal
Date proposal received by secretary
Date submitted to the board
Board decision
Date proposer notified
Date Rotary information session was held
Date signed card and remittance was received
Date membership was published to membership
Date the new member was inducted