Member Transfer Form

Civitan Club(Required)

Submitted By:(Required)

Name of club member completing this form

First Last

Submitter's Email Address(Required)

Form confirmation will be sent here

Transferring Member's Information

Member Name(Required)

First Last

Member Preferred Email(Required)

Member Preferred Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Sponsoring Member

Member's Previous Club

Club Member is Transferring FROM - the member will be deleted from this club. If the member does not wish to be deleted from the first club, and wants dual membership, you should fill out a New Member Addition form to add this member to your club instead.

Member's New Club

Club Member is Transferring TO