Your full name: * (Example: William J. Smith)

First name/Nickname — What you prefer to be called:
(Example: William, Bill, Will, Buddy)

Are you a Paul Harris Fellow? Yes No

Spouse name:   Not Applicable

Year you joined this Club:

Classification: (If uncertain, list profession and we'll resolve)

Your email address: * (Required)

Work Phone:   Not Applicable

Fax:   Not Applicable

Work Address: (Include ZIP Code)   Not Applicable

Cell Phone:   Not Applicable

Home Phone:   Not Applicable

Home Address: (Include ZIP Code)   Not Applicable (I'm either homeless or don't want my address listed.)

Primary phone contact for Rotary business: Home Work Cell
(This number is listed on the Club Roster page; all numbers are included on your individual popup page.)

Remarks:

When you have completed this form, click the "SUBMIT" button ONCE. The information will be sent to the Club webmaster and your roster information will be updated. A copy will also be sent to the Club Secretary.

To clear the form and start over, click the "Reset" button.