Membership Application for the Rotary Club of Boston #7


Applicant Name:  












Street Address


Current Position


City ST ZIP Code


Street Ad


Home Phone


City ST ZIP Code


Mobile Phone


Work Phone


E-Mail Address


E-Mail Address





If a current or former Rotarian, please list club(s) and approximate dates of membership:





If employed, please provide brief summary of professional positions held during past five years

If retired, please provide employer/profession and executive position at time of retirement.

Please indicate if self-employed; home office; on family leave of absence; student working on advanced degree.







Professional Degrees and Certifications (place and degree conferred )








Previous Volunteer Experience

Summarize special skills and qualifications you have acquired from employment, previous volunteer work, or through other activities, including hobbies or sports.





Languages skills:




The following are the Rotary's six areas of focus. Please indicate/highlight area(s) that interest you most:

       Economic & Community Development

       Disease Prevention/ Wellness


       Maternal-Child Health

       Peace/Violence Prevention

       Water Sanitation


Please provide two professional references that we can contact





Street Address


Street Address


City ST ZIP Code


City ST ZIP Code






E-Mail Address


E-Mail Address


Connection to applicant


Connection to applicant



Please return application within 30 days.

Agreement and Signature

I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a member, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal.



Signature (to be signed later at weekly luncheon meeting)


Sponsoring member of Boston Rotary (not required)



Our Policy

It is the policy of this organization to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability.


Thank you for completing this application form and for your interest in volunteering with us. 

If you have any questions regarding membership dues, charitable contributions, luncheon fees, or any part of this form, please contact: The Membership Chair at


Please save your completed application form as a MSWord file and send it attached to an Email to