Application / Referral Form (Cont)

Application / Referral Form (Cont).

Referral Information Complete this section if you are a Rotarian proposing the applicant.

Rotarians are adults of good character and good business or professional reputation, who hold or have held executive position with discretionary authority in any worthy and recognized business or profession. If you are an active member of a Rotary club in good standing and know someone suited to Rotary, please consider referring them for membership at the Rotary E-Club of Western Canada.

Prospective members should be aware that they can only be a member of one Rotary club at any given time. If you wish to join the E-Club, it will be necessary to resign your membership in your current club.

Referring Rotary Club Member’s Information

1. ☐I am an active Rotary Club Member 2. ☐I am an honorary Rotary club member.

3. ☐I am an officer and my current position is Click here to enter text..

4. District Number: 5. Rotary Club Name: Click here to enter text. Click here to enter text.:

6. First Name: 7. Last Name: Click here to enter text. Click here to enter text.

8. Daytime Phone #: 9. Evening Phone #: Click here to enter text. Click here to enter text.

10. Mobile Phone #: 11. Email: Click here to enter text. Click here to enter text.

12. Membership Number Click here to enter text.

Prospective Member / Applicant Information

13. First Name: 14. Last Name: Click here to enter text. Click here to enter text.

15. Profession: 16. Company / Employer: Click here to enter text. Click here to enter text. 17. Home Address Click here to enter text.

18. Daytime Phone #: 19. Evening Phone #: Click here to enter text. Click here to enter text.

20. Mobile Phone #: 21. Email: Click here to enter text. Click here to enter text.

22. Is the prospective member / applicant a former Rotarian: Choose an item. 23. If Yes, Membership Number: Click here to enter text. 24. Classification: Click here to enter text. 25. If Yes, list clubs and dates of membership: Click here to enter text.

26. Please list, if any, positions held at Club, District and Zone level in Rotary: Click here to enter text. 27. Additional Comments: Click here to enter text.

Please make sure you fill out the survey on the following page. New Member Survey Please provide us with some insight into your interest in Rotary. We would like to know where your passions lie in the service of others and Rotary. Please check all boxes that apply.

A) Are you interested in serving on our Board in any of ☐ I’d like to serve on the Board of Directors as Club these capacities? Secretary. ☐ I’d like to serve on the Board of Directors as Treasurer ☐ I’d like to serve on the Board of Directors as a President Elect ☐ I’d like to serve as a Committee Chairperson (see committees below) B) Among these “Avenues of Service” and “Areas of Focus” within Rotary, where would you be willing to Club Administration: serve? ☐ PR/Communications

☐ Social Media Development (Facebook / LinkedIn / Blogging)

☐ Club Fellowship (Coordinating)

☐ Membership Development

☐ Leadership Development / Training

☐ Fund Raising / Event Planning

☐ Rotary Foundation (Promote within Club)

☐ Global & District Grants (writing)

Community Service:

☐ Basic Education / Literacy

☐ Water & Sanitation

☐ Disease Prevention & Treatment

☐ Peace & Conflict Resolution

Form can be filled out electronically, saved and sent by email to [email protected] when complete. New Member Survey

☐ Maternal & Child Health

☐ Economic & Community Development

☐ Support Local Non-Profit Organization

☐ Coordinate Sport Events for Fundraising (Running, Biking, Walking for causes)

International Service

☐ Basic Education & Literacy

☐ Water & Sanitation

☐ Disease Prevention & Treatment

☐ Peace & Conflict Resolution

☐ Maternal & Child Health

☐ Economic & Community Development

Form can be filled out electronically, saved and sent by email to [email protected] when complete. New Member Survey C) Based on your vocation, would you be willing to Click here to enter text. share the talents and skills within Rotary? We call this “Vocational Service” and it is an “Avenue of Service” within Rotary.

What is your vocation and how do you see yourself using your skills and talents to serve others within the club or in the community or world?

Examples (just a few):  Doctor / Dentist – perform volunteer services abroad; build clinic / hospital.  Accountant – Help the club with managing finances.  Engineer – help design and build wells abroad.  Organizer – fund raise; event planning; administration for the club.  Education / Teacher – develop a literacy program for kids in our region or abroad.  Lawyer – share legal advice in community and club.  NGO – develop a link with E-Club for service opportunities.  Business Owner – help with fundraising and club planning.  Musician / Conductor / Arts Administrator – help form a youth orchestra for our District. D) What cause is most important to you and how do Click here to enter text. you see our Rotary E-Club helping to support this cause?

E) Your Comments / Questions? Click here to enter text.

Form can be filled out electronically, saved and sent by email to [email protected] when complete. New Member Survey

Form can be filled out electronically, saved and sent by email to [email protected] when complete.