Atlanta Tech Civitan Club
Please Print:
Name______________________________________________Nickname__________________________
Title_________________________________________________________________________________
Business______________________________________________________________________________
Address ______________________________________________________________________________
City _________________________________________________________________________________
State/Province____________________ZIP/Postal Code______________
Telephone (B)(_____)___________________(R)(_____)_____________________
FAX (______)_______________________________________________________
EMail Address______________________________________________________
Sponsoring Civitan___________________________________________________
Spouse's name______________________________________________________
Children_______________________________________________________
College/University (for students)________________________________________
Other organizations and civic activities_____________________________________________________
____________________________________________________________________________________ __
Please circle your special interest areas for Civitan Club work:
Budget/Finance Newsletter Awards
Fund Raising Community Projects Youth Work
Fellowship/Attendance Programs Scholarships
Social Activities Membership Growth Special Olympics
Publicity New Club Building Junior Civitan
Other (specify)_____________________________________________________
I hereby request membership in this Civitan club. Upon acceptance, I agree to be subject to its constitution, Bylaws, and official policies. I agree to pay the sum of $________as an initiation fee and to pay the regular dues to the club, district, and Civitan International as billed by the club. I understand that $2 of my annual dues shall be applied as a subscription to Civitan Magazine.
Applicant's Signature_________________________________________Date__________
For Transfers From other Civitan Club and Reinstatements Only:
Name___________________________
Former Civitan Club________________
Address_______________________________________________________
City____________________________
State or Province__________________
Postal Code______________________
To Be Completed By The Civitan Club
Approval:
________________________________________Date________________
Membership Chair Signature
________________________________________Date________________
Board of Directors Signature
________________________________________Date________________
Membership Approval
Club Secretary
New member reported to Civitan International with fee paid and sponsor noted.
________________________________________Date________________
Membership Chair Signature |
