MEMBERSHIP PROPOSAL FORM
ROTARY CLUB OF GREENVILLE, MS
P.O. BOX 367
GREENVILLE, MS 38702-0367
(To be completed by proposer and returned to the club secretary)
I propose:
Title (e.g. Mr., Ms., Mrs., Dr., Rev.) Suffix (e.g., Jr., Sr., III) _
Last Name: First Name: MI: _
Preferred or Nickname:______________________________
Birth Date: Name of Spouse _
Current (or former) firm and position: _
The principal business or professional activity of the firm or of the proposed member________________
Telephone (including area code) Fax (including area code)_
Residence _
Business _
Cellular
Preferred e-mail address: _
Mailing address for billing statements: _
Home Address _
If a transferring or former Rotarian, list club information below:
Club Name City State _
Date (from): Date: (to) _
Proposer (Print) Signature _
---------------------------------------------------- Club use only below this line-------------------------------------------------
Rec’d By Secretary Classification _
Membership Com. Action Board of Director’s Action _
Proposer Notified Date Inducted _
Kind of Member: Active Honorary _
07/13/10 form