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First Name:

Last Name:

Badge Name:

Email:

Club Name:

Preferred Phone:

Secondary Phone:

Address 1:

Address 2:

City:

Zip/Postal Code:

State/Province:

Business/Employer Name:

Position or Title:

Business Phone:

Business Email:

Date of Birth:

Spouse or Partners Name:

Some vocational and personal background details that will enhance your activities as a Rotarian:

What is your motivation to join Rotary Club of Keller?:

Keller Rotary has 4 fundraisers a year. Check the one you'd be most interested in participating:

Are you a military veteran?:

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If yes, what branch of service?:

Were you a previous Rotarian:

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Former Club name and RI id#:

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MEMBERSHIP APPLICATION KELLER ROTARY CLUB

MEMBERSHIP APPLICATION

KELLER ROTARY CLUB