Membership Application Form

Lance Lewis, Governor

Chesapeake District Civitan Club Membership Application

I hereby request Civitan membership in the

Upon acceptance by the members, I agree to be subject to the Constitution, Bylaws and Official Policies of this club. I agree to pay the initiation fee, and to pay the regular periodic dues as billed by the club's treasurer. A portion of this payment will be used for Chesapeake District and Civitan International dues. I understand that $2.50 of my annual dues shall be applied to a subscription to Civitan Magazine.

Please complete 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:

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

Comments:

Signature:____________________________________________________________

Please print and give to a member of the club you wish to join.