Name of Business:

Type of Business:

Business Address:

Business Phone:

Fax:

Email:

Website:

Primary Employee Designated to Represent Company:

Employee’s Home Address:

Position Title or Description:

Mobile:

Employer:

Employer’s Address:

Position Title or Description:

Work Email:

Work Phone:

Partner’s Name:

Children’s Names (and their ages if under 18):

Proposed Classification (i.e., Education, Administrator, Health Services, Sports Coach):

Prior Rotary Club:

Name of Club:

Some vocational and personal background details which you would like to share:

Other Employees Who May Represent Your Business at Rotary Meetings (up to three):

Name:

Name:

Name:

Phone:

Phone:

Phone:

I hereby certify that if accepted to Membership of the Rotary Club of Newberg

that I, as a Rotarian, will exemplify the Object of Rotary in all my daily contacts and will abide by the constitutional documents of Rotary International and the club. I agree to pay dues and other fees in accordance with the bylaws of the club.

Signature:

Date:

Nominated by:

Board Approved on:

Name:

Home Address:

Home Phone:

Mobile:

Business/Employer Name:

Position Title or Description:

Business Address:

Business Phone:

Fax:

Email:

Date of Birth:

Sponsor’s Name (if applicable):

Children’s Names (and their ages if under 18):

Would you like to be added to the Rotary of Newberg database? Doing so, you will receive emails regarding the Rotary Club of Newberg weekly meetings, events & announcements.

YOUR AREAS OF INTEREST: Check all that apply

Signature:

Date: