This Form to Be Used with Immediate Effect. Please Destroy All Previous Forms

Form

Revised July 2012

–

This form to be used with immediate effect. Please destroy all previous forms.

Membership Proposal Form Part A (to be completed by proposer)

TO THE COUNCIL OF THE ROTARY CLUB OF

I Propose:

Title:

______

Full Name:

______

Address:

______

Telephone

(Including country/city or area codes)

Fax (including country/city or area codes)

Private:

______

______

Business:

______

______

Mobile:

______

EmailAddress:

______

Proposed Classification:

______

If rejoining ora former Rotarian, list his/her most recent club information: Previous club name:

______

Dates:

______

______

From

To

Previous Rotary membership

ID

number:

______

Recent Rotarian (one year or less)

Yes

No

Proposer’sSignature

Date

Part B (to be completed by proposed member)

I, the undersigned, hereby consent to this proposal for membership in the Rotary club being examined in accordance with the constitutional procedures of Rotary International in Great Britain and Ireland. I accept that enquiries will need to be made about me. I am willing to meet members of the club to provide further information and to learn more of the particular obligations and privileges of membership. I understand that if I wish this proposal to be considered further the above particulars will be circulated to all current members, but if at any time I wish this proposal to be withdrawn no further action will be taken. I also understand that in the event of there being objections my application may not be successful, and that reasons for not inviting me to membership will not be given. If invited into membership I agree to accept and be bound by the Constitution and By-laws of the Rotary Club for the time being in force.

Data Protection, RI & RIBI Collection and Use of Personal Membership Data:

As part of its effort to assist clubs and districts and facilitate communication with Rotarians, Rotary International and Rotary International in Great Britain and Ireland collects personal information about Rotary club members, and their partners and associates where appropriate, to be used solely for the purpose of conducting core business activities, these include:

• Preparing the annual RI, RIBI, Rotaract and Interact Directories

• Calculating semi annual dues payable to Rotary International

•Identifying prospective candidates for presidential and Foundation appointments to conferences, RIBI, RI and TRF committees, taskforces, and other assignments

• Supporting The Rotary Foundation

• Providing information and updates to district governors, district officers and others involved in RI and RIBI programs and service projects

• Providing goods and services to clubs and districts for their general activities

• Providing guidance to clubs and districts in their general activities and public relations efforts

• Communicating key organisational messages and information to district leaders and to clubs for dissemination at the club level

• Facilitating conference, assembly and special event planning

• Supporting ‘The Rotarian’ and the RIBI regional magazine ‘Rotary Today’

• Identifying Rotarians who have specific language and/or professional skills

At the direction of the General Council of RIBI, RIBI may occasionally participate in special advertising and/or marketing initiatives that involve the release of membership information. RIBI will notify Rotarians about these initiatives and their particulars will not be released without their express consent. RIBI may also disclose information as required by law or if pertinent to judicial or governmental investigations.

For RI Privacy Statement, see RI website: Please help us build an accurate profile of our members by answering the following questions.

These questions are optional:

Date of Birth:

______

Male:

Female:

How did you hear about Rotary?

______

Proposed Member’s Signature

Date

Form revised July 2012

–

Thisform to be used with immediate effect. Please destroy all previous forms.

Part C (to be completed by a club officer)

Classification:

______

If member is a former Rotarian, provide previous club and district information:

Club name:

______

District number:

______

Club ID number:

______

Dates:

From:

______

To:

______

Rotary membership ID number*:

______

Name of Mentor assigned to assist with orientation:

______

Rotary magazine subscription:

The Rotarian

Rotary Today

Action on Proposal Date

Received by club secretary

______

Former Rotary club contacted (if former Rotarian): In good standing

Not in good standing

Submitted to membership committee:

______

Committee decision received:

______

Approved

Disapproved

Submitted to club council:

______

Council decision received:

______

Approved

Disapproved

Proposed to club:

______

(If any objection has been filed, the council should address the issue at its next meeting.)

Final approval by council:

______

Signed form and admission fee received:

______

Admitted tomembership:

______

Entered into Member Access:

(Club officers should also refer to the Electing a Rotarian Flow Chart that supports the Proposal for Membership Form, available on the RIBI website)