Rotary e-Club of NextGen Membership Application

Membership Application

Please fill in the form below.
Full Name?*

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E-mail?*
Date of Birth?*

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Gender?*

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Partner's Name?

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Mobile Number?*

Phone Number
Phone Number?*

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Address?*

Street Address

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Employer or Name of Business?
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Rotary Magazine Preference?*

Rotary Down Under (Hard Copy)The Rotarian (Electronic Copy)
My referee is?

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I have viewed the website and believe my interest is in? *
I have previously held these positions within a service organisation?
Are you a current Rotarian?

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RI Number (if current Rotarian)?
PHF Level (if applicable)?
District (if applicable)?
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