Lincoln Rotary Club #14 : Membership : Membership Proposal Form

Complete the proposal form as thoroughly as possible. Your assistance will speed up the membership review and classification process.

First Name *REQUIRED*

Last Name *REQUIRED*

Residence Address (Line 1)

Residence Address (Line 2)

Residence City

Residence State

Residence Zip Code

Residence Phone

Residence Fax

E-mail Address

for (check one) *REQUIRED*

If former Rotarian, list club(s) and date(s)

Name of Organization

Organization Address (Line 1)

Organziation Address (Line 2)

Organization City

Organization State

Organization Zip

Organization Phone

Organization Fax

Principal Activity of Organization

Candidate's Position/Title

Length of Time in This Position

Does the candidate spend at least 60% of their time in this position?

Is the candidate in a management position?

Will the candidate be able to attend Rotary meetings and participate in Rotary activities?

Describe how the candidate has demonstrated leadership in their profession

Describe how the candidate has demonstrated leadership in community service

If retired, list position and employer at time of retirement

List another Rotarian as a reference for this candidate

Proposer's Name *REQUIRED*

Proposer's Phone *REQUIRED*

Proposer's E-mail *REQUIRED*

Checking this box constitutes an electronic signature *REQUIRED*

Proposed Date *REQUIRED*