The Rotary Club of Glens Falls
Box 4702
Queensbury, NY 12804-4702

Prospective Membership Application

(Please read, fill out completely, date, and sign)

                                                                                       Date:                                      

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: ____________________

State:_________ Zip:________________

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:______________________________

Dates:___________________________________ Dates:___________________________________

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:

• ·      1^st — Is it the TRUTH?
• ·      2^nd— Is it FAIR to all concerned?
• ·      3^rd —Will it build GOOD WILL and BETTER FRIENDSHIPS?
• ·      4^th— 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—

- • -                   - • -                               - • _ • -

! To be completed by a club officer: Classification:

If transferring or former Rotarian, previous club information: Name

From                                To

Mentor assigned to assist with orientation:

Rotary magazine subscription:

• [ ] The Rotarian [] Rotary regional magazine