Civitan International Charter Membership List

The Charter Membership List for the Civitan Club of

(City), (State) in the District. Double-check the spelling of the names and addresses on this list. Civitan International uses the information from this list to enter the charter members in the computer. Credit for sponsoring the charter member should go to the person who is responsible for recruiting the member into the club. Charter members may sponsor other charter members! However a member may not sponsor himself/herself. Only one sponsor may be shown for each member. In addition to this Charter Membership List Civitan International requires that each charter member’s application be submitted for the club’s permanent file. Indicate Member Type: N – New T – Transfer R – Reinstate S – Full-time Undergraduate Student. Include the $15 initiation fee for each new Civitan charter member plus $2.50 for insurance; $5 for reinstated Civitan members, plus $2.50 for insurance. (There is no charter fee for transfer members currently on the rolls of another Civitan club. A club may not have more than 20 percent of its members who are transfers, reinstated, or dual members.) A Dual member (member of more than one club) is shown as new member and pays same fees as new member. There is no fee for a former Campus or Junior Civitan coming into a senior Civitan club, no matter how long since he or she was in Campus or Junior Civitan. The former Campus or Junior Civitan club must be listed, however, and he or she will be listed as a transfer member. List former club and approximate date of membership for each member that is a transfer, a reinstate, a former Campus Civitan, or a former Junior Civitan. If dual member or paying half dues, indicate that in Former Club blank. For address, please give preferred mailing address. Please type or print.

Name: Sponsor: 1 Address: I Check one: N T R S D Former Club - Date: City: I Home: Work: Cell: State/Province: Zip Code E-mail:

Name: Sponsor: 2 Address: I Check one: N T R S D Former Club - Date: City: I Home: Work: Cell: State/Province: Zip Code: E-mail:

Name: Sponsor: 5 Address: I Check one: N T R S

CF210 (over) Charter Membership List—Page 2

City: I D Former Club - Date:

State/Province: Zip Code: Home: Work: Cell:

E-mail:

Name: Sponsor: 1 Address: I Check one: N T R S 0 D Former Club - Date: City: I Home: Work: Cell: State/Province: Zip Code: E-mail:

Name: Sponsor: 1 Address: I Check one: N T R S 1 D Former Club - Date: City: I Home: Work: Cell: State/Province: Zip Code : E-mail:

Name: Sponsor: 1 Address: I Check one: N T R S 3 D Former Club - Date: Charter Membership List—Page 3

City: I Home: Work: Cell:

State/Province: Zip Code: E-mail:

NameI Sponsor: 2 Address: I Check one: N T R S 1 D Former Club - Date: City: I Home: Work: Cell:

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State/Province: Zip Code: E-mail:

Name: Sponsor: 2 Address: I Check one: N T R S 9 D Former Club - Date: City: I Home: Work: Cell: State/Province: Zip Code: E-mail: Charter Membership List—Page 5

Name: Sponsor: 3 Address: I Check one: N T R S 4 D Former Club - Date: City: I Home: Work: Cell: State/Province: I Zip Code: E-mail:

Name: Sponsor:

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3 Address: I Check one: N T R S 8 D Former Club - Date: City: I Home: Work: Cell: State/Province: Zip Code: E-mail:

Name: Sponsor: 4 Address: I Check one: N T R S 2 D Former Club - Date: City: I Home: Work: Cell: State/Province: I Zip Code: E-mail: I

Name: Sponsor: 4 Address: I Check one: N T R S 4 D Former Club - Date: City: I Home:I Work: Cell: State/Province: I Zip Code: E-mail:

Name: Sponsor: 4 Address: I Check one: N T R S Charter Membership List—Page 7

6 City: I D Former Club - Date:

State/Province: I Zip Code: Home: Work: Cell:

E-mail:

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