<p> Rotary International Dominican Republic Friendship Exchange Application District 6040, Missouri, USA</p><p>Santo Domingo and Dominican Republic February 1-15, 2013</p><p>Please print or type. Do not use initials. </p><p>Name in full ______First Middle Last Date of Birth</p><p>Name in full ___ First Middle Last Date of Birth</p><p>Mailing Address Number & Street City/Town State Postal/Zip Code</p><p>Phone Home Office Fax E-mail</p><p>Person or persons to notify in case of emergency ( name, address, e-mail, phone number, and relationship) _____ </p><p>Your occupation/Rotary Classification </p><p>Spouse occupation and or Rotary Classification </p><p>Rotary Information ______Member of Rotary Club Date of Membership</p><p>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.</p><p>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</p>