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Waterloo Downtown Rotary Club

Membership Proposal Form

Name: _______________________________________________________________________

Business Name/Address: _________________________________________________________

_________________________________________________________

Phone (Cell/Work/Home): ______________________________________________________

Other Phone (Cell/Work/Home): ________________________________________________

Email: _________________________________________________________

Address (Home/Work): _________________________________________________________

If a former Rotarian, list club and dates:

_________________________________________________________

_________________________________________________________

Name of firm and executive position (former firm and position, if retired):

_________________________________________________________

_________________________________________________________

Activities which would enhance consideration as a Rotarian:

_________________________________________________________

_________________________________________________________

I hereby certify that I am qualified for membership both by the current/former executive position and by having a place or residence within the club’s territorial limits, adjoining territory, or the same city in which the club is located.

I understand that it will be my duty, if elected, to exemplify the Object of Rotary in all my daily contacts and activities and to abide by the constitutional documents of Rotary International and the club. I agree to pay an initiation fee of $50.00 and the annual dues of $600.00 in accordance with the bylaws of the club. I hereby give permission to the club to publish my name and proposed classification to its membership.

_____________________________________ _________________________________________

Proposed Member’s Signature Proposer’s Signature

_____________________________________ _________________________________________

Date Date

Automatic Deduction Sign Up

Direct debit is a safe and secure way to have your payment deducted directly from your checking or savings account. Direct debit is reliable and convenient; you don't have to worry about writing a check or being late. Our Rotary Club currently utilizes the ACH payment system provided by Farmers State Bank. All information is stored with that bank and not with our club or club executives.

I hereby authorize a direct debit for the following from the account and financial institution listed below (please select all that apply):

⇨ Rotary Club Dues (including guest meals)

⇨ Voluntary Birthday Contribution

⇨ Paul Harris Contribution

Amounts will be pulled as follows:

• Quarterly on January 2, 2019 and April 1, 2019

• Annual thereafter on the first business day in July

Name: _____________________________________________________________

Name on Account: _____________________________________________________________

Bank Name: _____________________________________________________________

Account Type:

⇨ Checking

⇨ Savings

ABA (Routing Number): ___________________________

Account Number: _________________________________

Begin Date ____________________

End Date ____________________

Authorizing Signature: __________________________________ Date: ____/ _____/ _______

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