Membership Application Form

Chesapeake District Civitan Club Membership Application

I hereby request Civitan membership in the

Upon acceptance by the members, I agree to be subject to its Constitution, Bylaws and Official Policies of this club. I agree to pay the initiation fee, and to pay the regular monthly dues as billed by the club's treasurer. A portion of this monthly payment will be used for Chesapeake District and Civitan International dues. I understand that $2 of my annual dues shall be applied for a subscription to Civitan Magazine.

Please fill out the following form, print, sign, and give to a member of the club you wish to join.

Date of Application:

Name:

Address:

Address (line 2):

City: State: Zip:

Home Phone :

Business Phone : Extension:

E-Mail:

Would you like your e-mail added to the 'Contact Information' page of our website? Yes No

Were you referred to this site by a member of Civitan? Yes No

Comments:

Signature:____________________________________________________________

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