Join Rotary - South Salem Rotary Club

Applicant Name*
First Middle Last
Professional Certifications
Applying For...*
- Active Membership
- Retired Membership
- Transfer from another Club
Name of previous Rotary Club*
Home Address*
Street Address Address Line 2 City State ZIP Code
Email Address*
Home Phone*
Business or Organization*
Name of business, organization, etc. where you work
Occupation or principal activity*
If retired, occupation at time of retirement
Work Address*
Same as Home Address

Street Address Address Line 2 City State ZIP Code
Work Phone*
Community or Professional Activities
List community activities, professional affiliations, or other activities that might enhance your consideration to become a Rotarian.
Sponsoring Rotarian
Name of the current Rotarian sponsoring you for membership
Name
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