CANDIDATE INFORMATION CONFIRMATION:

First Name:

Middle Name(s):

Last Name:

Title (Mr./Mrs./Miss/Ms./Dr./Prof. etc):

Suffix (Honours):

I would like to be known in the Club as:

Partner's First Name:

Partner's Last Name (only if DIFFERENT to yours):

WORK INFORMATION:

Name of Company/Organisation:

Position in Company/Organisation:

WORK - Address:

WORK - Suburb/City:

WORK - State:

WORK - Postcode:

WORK - Phone number:

WORK - Fax:

HOME INFORMATION:

HOME - Address:

HOME - Suburb/City:

HOME - State:

HOME - Postcode:

HOME - Phone Number:

HOME - Fax:

POSTAL INFORMATION: (only required if POSTAL address is DIFFERENT from Work or Home Address)

POSTAL - Address:

POSTAL - Suburb/City:

POSTAL - State:

POSTAL - Postcode:

Send Mail To This Address:

MOBILE PHONE AND EMAIL INFORMATION:

Mobile Phone Number:

Preferred Email Address:

OTHER CLUB INFORMATION:

My Date of Birth is:

My Sponsor into the Club is:

I have previously been a member of the following Rotary Club(s):

(Please include date(s) of joining and resignation)

My current employment status is (F/T, P/T, Semi Rtd, Rtd):

Your Classification is: (this field is NOT TO BE AMENDED using this form - please contact your Sponsor if your classification does not represent your current vocation/expertise):

CONGRATULATIONS ON COMPLETING THIS NEW MEMBER INFORMATION CONFIRMATION - TAKE A BOW!!

NOW, PLEASE CLICK ON THE "SUBMIT" BUTTON BELOW TO SEND YOUR INFORMATION TO THE CLUB.  (Please be patient if the upload takes a little time - we need to be sure that our system receives your details correctly!)