Rotary Wheel Letterhead

Rotary International Dominican Republic Friendship Exchange Application District 6040, Missouri, USA

Santo Domingo and Dominican Republic February 1-15, 2013

Please print or type. Do not use initials.

Name in full ______First Middle Last Date of Birth

Name in full ___ First Middle Last Date of Birth

Mailing Address Number & Street City/Town State Postal/Zip Code

Phone Home Office Fax E-mail

Person or persons to notify in case of emergency ( name, address, e-mail, phone number, and relationship) _____

Your occupation/Rotary Classification

Spouse occupation and or Rotary Classification

Rotary Information ______Member of Rotary Club Date of Membership

Rotary Offices held, District or Club Projects Chaired Please attach a sheet giving: 1) personal, business and family information (your biography), 2) list any allergies and/or medical information that might be pertinent when traveling, and 3) Team members & spouses agree to host incoming team and assist with scheduling. Tentative travel date to the USA/District 6040 is September or October, 2013. NOTE: Travel restrictions require a USA Passport for travel to/from the Dominican Republic.

Rotarian Signature Spouse Signature ______Date Please submit a $100.00 check with application payable to: R.I. District 6040 RFE Mail to: Dan Hall, 2713 NW Cliff View Dr., Lee’s Summit, MO 64081 E-mail: [email protected] Phone: 816-803-1048