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Yadkin Valley Rotary Club
Membership Proposal Form

I propose:

Name___________________________________________________________________

Residence Address_________________________________________________________

Residence Phone Number___________________________________________________

Business Address_________________________________________________________

Business Phone Number____________________________________________________

for (check one ): ( ) active       ( ) honorary membership

If former Rotarian, list club(s) and dates:________________________________________

Proposed classification _____________________________________________________

Name of firm and executive position (former firm and executive position, if retired:

_______________________________________________________________________

________________________________________________________________________

Name & phones numbers of at least three Rotarians who know the Proposed Member and who may be contacted confidentially:

(1)_____________________________________________________________________

(2)_____________________________________________________________________

(3)_____________________________________________________________________

How long have you known the proposed member?________________________________

Activities which would enhance a consideration as a Rotarian:_______________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

________________________________________________________________________
DATE                                                   Proposer's Signature

Yadkin Valley Rotary Club
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XXX ????? St. Elkin, NC 28621
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336.835.XXXX
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© 2004 YVRC