Rotary Club of New York
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-
and our membership committee referenced on page 2. Credit
Card Payments are accepted for your convenience.
Nickname for badge:
Bus. Phone: (
Bus. Fax: (
Home Phone: (
Home Fax: (
Preferred E-Mail Address:
Preferred Mailing Address:
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?
# of years
Paul Harris Fellow?
Name of Spouse/Partner:
Name/Ages of Children:
Date of Birth:
Military Branch, if any:
College Degrees, Professional Designations held:
College or University(ies) attended:
Hobbies, special interests, foreign languages, etc:
Rotary Club of New York • 322 Eighth Avenue, #1701 • New York, NY 10001 • (212) 633 1311