Dsyp Membership App

K I WA N I S

M E M B E R S H I P

I N F O R M AT I O N S e r v i n g

t h e

C h i l d r e n o f

t h e

W o r l d

Full Name____________________________________Nickname_________________ Gender______ Home Address_________________________________________________________________________________________________________ City

State/Province

Zip/Postal Code

Home Phone__________________________________Spouse’s Name______________________ Company Name_________________________________________Title________________________________________ Business Address______________________________________________________________________________________________________ City

State/Province

Zip/Postal Code

Business Phone________________________________Fax Number _______________________ E-Mail Address________________________ Send Kiwanis mail to: Home

Work

If you are a former Kiwanian:

Club Name________________________________________Date Left (mo/day/yr)__________ Length of Membership___________If you are a life member, life member #_____________________

Date of Birth:_________________ (mo/day/yr)

Committee Preference Club Administration Community Service

I accept this application for membership and agree to conform to the bylaws of this club and comply with the obligations of membership as explained to me by my sponsor. Date: _________

Applicant Signature: ___________________________________________

(mo/day/yr) C H E C K O N E B L O C K P E R C AT E G O RY

PRIMARY EMPLOYMENT Codes 1 3 5 7 9 11 13 15

Banking/Finance Comm/Media Construction Education Government Legal Manufact.(Heavy) Manufact.(Light)

17 19 21 23 25 27 29 94

Medical Nonprofit Real Estate Religion Retail Transportation Wholesale Other

JOB CLASSIFICATION

EDUCATION ATTAINED

Codes

Codes

N. O. P. Q. R. S. T. V. X.

Elected Management Partner/Owner Professional Sales Supervision Technical Retired Other

A. B. C. D. E. F. G.

Grade School High School Tech.Business School Assoc. Degree (2 yrs.) Baccalaureate Degree (4 yrs.) Master’s Degree Grad. Prof. Degree

Note: For membership statistics only. Kiwanis International does not provide its membership information to third parties.

Receipt

Date _______________ (mo/day/yr)

Received of __________________________________________________________________$ _________________

Cash or Check

For_____________________________________________________________________________ Received by _______________________________

New Member Sponsor To the Board of Directors of the Kiwanis Club of ______________________________________________________________, I take pride in proposing __________________________________________________________________________________, as an active member of the club and have confidence that this individual will become a valuable member. Date:___________

Sponsor Name:________________________________________________

(mo/day/yr)

Sponsor Signature:______________________________________ Additional Club Member:_____________________________

Recommended by Membership Committee Date: ___________

Chairman Signature: _______________________________________________________________________

(mo/day/yr)

Membership Class: ________________________________ Suggested Classification: _________________________________

Elected to Membership by Board of Directors Date: ___________

Secretary Signature: _______________________________________________________________________

(mo/day/yr)

Member Accomplishments Total Years of Perfect Attendance ___________ Offices Held: ______________________________________________________________________________________ Awards: __________________________________________________________________________________________ _________________________________________________________________________________________________