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