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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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