APPLICATION FOR ROTARY DISTRICT 5550 INVOLVEMENT

Last Name (Surname) Given Name
Address (Number & Street) City/Town Province Postal Code
Telephone number – where we will contact you :
Home: Business:
e-Mail Address:
Kind of involvement desired:
Home rotary club:
Have you served in the district before? YES NO
If yes, kind of involvement? When:
 
List Rotary experience (include years in Rotary and involvements):
 
Please provide a brief overview of your related experience, interests, hobbies, positions, training, education, and time availability to devote to the district now and over the next three years.
 
Please provide 3 references; two should be from rotary members.
Name Address & Contact Information
 
Date: Signature:

Once you have complete the form submit to District.