Home • Membership • Application Form Application Form "*" indicates required fields Step 1 of 3 33% EmailThis field is for validation purposes and should be left unchanged.General DetailsFirst Name*Last Name*Nickname (If Any)Date of Birth MM slash DD slash YYYY City / State of Birth*Home Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Mobile Phone*Home Email* Firm / Organization DetailsName of Form / Organization*Position*Business Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Business Phone*Business FaxBusiness Email* Business WebsiteDescribe the type of business in which your firm engages* Rotary QuestionsWhat do you hope to get out of your Rotary membership and which committees are you interested in joining?*To what organizations do you belong? (Professional, Civic, Social, Charitable)*Are you a current / former member of any other Rotary Club? Yes No Dates of membershipLA5 members are business and civi leaders, but they also enjoy time outside work. Can you tell us more about your family, life, interests, hobbies, and weekend activities?*Undergraduate Affiliation & Degrees*Graduate Affiliation & Degrees*Military Service / RankForeign Languages SpokenMusical Instruments PlayedPublic Offices HeldHow would you like to pay your dues?Associate Member (35yo or under) - $253 per monthRegular Member (over 35yo) - $262 per monthAssociate Member (35yo or under) - $2,955 per yearRegular Member (over 35yo) - $3,055 per yearI understand and agree to the financial responsibilities involved with becoming a member of this club. Yes, I understand There is a one-time initiation fee, and either annual or monthly dues that includes lunch and parking. Please ask our membership committee for more information if you need more information.Have you attended three or more Rotary lunches or events? Yes No Primary Sponsor Name*Secondary Sponsor Name (1)*Secondary Sponsor Name (2)*Today's Date* MM slash DD slash YYYY Please upload your resume*Accepted file types: pdf, Max. file size: 128 MB. One file only. 128 MB limit. Allowed types: PDFPlease upload a digital photo in JPG format for use in the LA5 membership directoryAccepted file types: jpg, Max. file size: 128 MB. One file only. 128 MB limit. Allowed types: JPG
