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| Civitan Membership Application |
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An invitation for membership will be extended only after due consideration of this club in accordance with its Constitution, Bylaws, and policies.
Pioneer Ladies Civitan Club
(Please Print):
Name_________________________________________
Business ______________________________________
Title __________________________________________
Address _______________________________________
City ___________________________________________
State/Province _______________ Zip Code ___________
Telephone (B)________________________
(H) _______________________
Fax ( ) __________________
E-Mail Address _________________________________
Sponsoring Civitan _______________________________
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 $17.50 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
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