Application -

Name *

First

Last

Email *

Gender

Mailing Address *

Office Phone

Mobile Phone *

Education

Employer

Occupation / Title

Personal Hobbies and Interests

Community Service Experience and Interest

Why do you want to join Rotary E-Club of the West

How did you hear about Rotary E-Club of the West

Have you had previous Rotary affiliation?

Previous Rotary affiliation (If applicable)

Rotary Membership Number

Please list 3 references below including name, phone number, and relationship to you

Letter of Good Standing

If you are a former Rotarian, please provide a letter from your previous Club’s President stating that you left in good standing and without debt to the Club. This may be sent via email or in a Word document to rosalind@RStarFoundation.org. Please list 3 references below including name, phone number and relationship to you. Annual membership fees are $300. A one-time $25 initiation fee is required to process your application. Please send to Rotary E-Club of the West Attn: Rae Beimer, 10436 E. Monterey Ave., Mesa AZ 85209-7846

Application

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