The Rotary Club of Glens Falls
Queensbury, NY 12804-4702
Prospective Membership Application
(Please read, fill out completely, date, and sign)
Title (e.g., Mr. Ms., Mrs., Dr., Rev., Col.)______________ Suffix (e.g., Jr., Sr., Ill, etc.)___________
Name: First:______________________ Middle:_____________ Last:_____________________
Current (or former) Firm and Position:_________________
Length of time in that position: ____________ Business Address:____________________
City:___________________________ State:______ Zip:_____________________________
Home Address:_______________________________________ City: ____________________
Number of years you have lived in our area:__________ Worked in our area:________________
Home Phone: ( ) Business Phone: ( ) ext:
Fax: ( ) Cell Phone: (
Preferred e-mail address: [ ] Home [ ] Business________________________________________
Formal Education / Training:_____________________________________________________
Your Date of Birth': Spouse/Partner's Name:_____________ Spouse/Partner's Last
Name:___________________ Spouse/Partner's Date of Birth':_ Wedding Anniver-
sary:1 ____________________________________ Children [Name, Gender, Age]:_______________________________
(You may use additional paper)
Club Sponsor:___________________ Employment Classification:________________________
If a transferring or former Rotarian, list previous club information: (You may use additional paper)
Club Name:____________________________ Club Name:______________________________
From To From To
Recent Transfer (One year or less): [ ] Yes [ ] No
If a Club Officer, an RI program participant, or Foundation alumnus/a, list specifics with dates:
Interests, Hobbies, Activities that would enhance consideration as a Rotarian; i.e., list of community events in which applicant has participated / assumed a leadership role (You may use additional paper):
Applicant's Signature:_____________________________________________________ Date:____________________________________
Remittance Received: $___________ RI Notified_________________ Secretary:____________________________________________________
The Rotary International Four-Way Test
The FOUR-WAY TEST of the things we think, say or do:
- · 1st — Is it the TRUTH?
- · 2nd— Is it FAIR to all concerned?
- · 3rd —Will it build GOOD WILL and BETTER FRIENDSHIPS?
- · 4th— Will it be BENEFICIAL to all concerned?
To Be Completed by the Sponsor:
Activities which would enhance consideration as a Rotarian:________________________________
Date Proposer's Signature
Membership in Rotary
Each active member shall be an adult of good moral character and good business and professional reputation meeting the qualification of Article IV, section 3 of the "Constitution of Rotary International."
Statement to Be Signed by Proposed Member After Club's Board Has Approved the Proposal
I hereby certify that I am qualified for Active membership by both my current/former executive position and having a place of business or residence within the club's locality or surrounding area.
I, the undersigned, being familiar with the requirements for, and consideration of membership contained in the constitution and by-laws, hereby make application for membership in the Rotary Club of Glens Falls, Active Membership under the Classification of_________________________________
I understand that it will be my duty, if elected, to exemplify the Object of Rotary in all my contacts and activities and, at all times abide by the Constitution and By-Laws of this club. I agree to pay an initiation fee* of $50.00 and the annual dues of $_____________ in accordance with the bylaws of the Club. I hereby give permission
to publish my name and proposed classification.
Applicant's Signature Date__________
Remittance Received $ RI Notified________ Secretary__________
*Not applicable to honorary members or transferring or former members of another club.
Rotary Club of Glens Falls
Prospective Member Application —page 2—