Applicant Name:  

Personal

Professional

Partner

Employer

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 )

Undergraduate

Graduate

Certifications

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:

Please provide two professional references that we can contact

Name

Name

Street Address

Street Address

City ST ZIP Code

City ST ZIP Code

Telephone

Telephone

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.

Date

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 communications@bostonrotary.org