Member Proposal Form

ROTARY CLUB OF BREVARD

MEMBERSHIP PROPOSAL FORM

I propose: 

Name ________________________________________________________________________

Business Address ______________________________________________________________________                                                                      

Telephone ___________ Fax ____________  E-Mail ________________________________

Residence Address ________________________________ Telephone ________________

Home Fax _______________ Home  E-Mail _______________________________________

For (check one)          Active Membership               Honorary Membership

If a former Rotarian, list club(s) and date(s): _______________________________________

Proposed classification (if Active): ________________________________________________

Name of firm and executive position (former firm and executive position if retired):

Activities that would enhance consideration as a Rotarian:

Date___________  Proposer  _____________________________________________________                                                                                         (Signature)

Statement to be signed by Proposed Member AFTER the Board has approved

the proposal:

Proposed Member’s Name: ______________________________________________________

I hereby certify that I am qualified for membership both by my current/former

executive position and by having a place of business or residence within the

club’s locality or surrounding area.

I understand that it will be my duty, if elected, to exemplify the Objects of

Rotary in all my daily contacts and activities and to abide  by the constitutional

documents of Rotary International and the Rotary Club of Brevard. I agree to

pay an admission fee of  $___________, and the annual dues of  $_____________

in accordance with the bylaws of the Rotary Club of Brevard. I hereby give

permission to the club to publish my name and proposed classification to

its membership.

Date ______________   Proposed Member’s Signature ________________________________

RECORD OF ACTION ON THE PROPOSAL

Received by Club Secretary on: __________________________________________________

Submitted to the Board of Directors on: ___________________________________________

Board decision on: ______________________                    Approved        Disapproved

Proposer notified on: ___________________________________________________________

Rotary information session (orientation) held on: ___________________________________

Orientation session held by: _____________________________________________________

Signed card and admission fee and dues received on: ______________________________

Publication of name to membership on: ___________________________________________

Inducted on: ___________________________________________________________________

Classification: __________________________________________________________________

Committee Assignment: _________________________________________________________

Badge Ordered and presented on: ________________________________________________

Membership Card presented on: __________________________________________________