Microsoft
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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