Rotary Club Of New York Membership Profile

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Rotary Club of New York
Membership Profile
Return this form and a $500 refundable application fee to begin your membership process.
(After approval by the Board of Directors, this fee becomes the initiation fee and is non-refund-
able.) Within the week, following submission of this application, please provide your “New
Member Bio” in the Rotary Format attached and a digital photo in jpg format. Send this infor-
mation to:
and our membership committee referenced on page 2. Credit
ny.rotary@verizon.net
Card Payments are accepted for your convenience.
Name:
Nickname for badge:
Date:
/
/
Company Name:
Your Department:
Website:
Bus. Address:
City:
State:
Zip:
Bus. Phone: (
)
Bus. Fax: (
)
Bus. E-mail:
Home Address:
City:
State:
Zip:
Home Phone: (
)
Home Fax: (
)
Home E-mail:
Preferred E-Mail Address:
HOME
WORK
Preferred Mailing Address:
HOME
WORK
(Circle one)
(Circle one)
Professional Title or Function:
Time with this company:
Time in this industry:
Describe your company
(What does it do? Who does it serve? How many employees? HQ Location?):
Describe briefly the duties you perform:
How many people do you supervise?
Rotarian references, if any:
List past and present civic, charitable, nonprofit organization activities:
Other club memberships, trade, professional memberships:
Have you been a member of this or any other Rotary Club?
Where?
# of years
When?
Paul Harris Fellow?
Personal Information
Name of Spouse/Partner:
Name/Ages of Children:
Date of Birth:
/
/
Anniversary Date:
/
/
Military Branch, if any:
College Degrees, Professional Designations held:
College or University(ies) attended:
Hobbies, special interests, foreign languages, etc:
Interviewer/Co-sponsor
Date
Sponsor
Date
Rotary Club of New York • 322 Eighth Avenue, #1701 • New York, NY 10001 • (212) 633 1311

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