|
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. |
| 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. |