New Member Addition 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

New Member Information

New Member Name(Required)

First Last

New Member Birthdate (mm/dd)

New Member Preferred Email

New Member Preferred Phone Number

Preferred Phone Type

New Member Preferred Address

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

Sponsoring Member

Does this member qualify for reduced dues status per Civitan International Policy?

If yes, please select the reason:

Do you need to add a second new member?

Yes

New Member #2 Name(Required)

First Last

New Member #2 Birthdate (mm/dd)

New Member #2 Preferred Email

New Member #2 Preferred Phone

New Member #2 Preferred Address

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

Sponsoring Member - New Member #2

Does New Member #2 qualify for reduced dues status per Civitan International Policy?

If yes, please select the reason:

Do you need to add a third new member?

Yes

New Member #3 Name(Required)

First Last

New Member #3 Birthdate (mm/dd)

New Member #3 Preferred Email

New Member #3 Preferred Phone

New Member #3 Preferred Address

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

Sponsoring Member - New Member #3

Does New Member #3 qualify for reduced dues status per Civitan International Policy?

If yes, please select the reason:

Do you need to add a fourth new member?

Yes

New Member #4 Name(Required)

First Last

New Member #4 Birthdate (mm/dd)

New Member #4 Preferred Email

New Member #4 Preferred Phone

New Member #4 Preferred Address

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

Sponsoring Member - New Member #4

Does New Member #4 qualify for reduced dues status per Civitan International Policy?

If yes, please select the reason:

Do you need to add a fifth new member?

Yes

New Member #5 Name(Required)

First Last

New Member #5 Birthdate (mm/dd)

New Member #5 Preferred Email

New Member #5 Preferred Phone

New Member #5 Preferred Address

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

Sponsoring Member - New Member #5

Does New Member #5 qualify for reduced dues status per Civitan International Policy?

If yes, please select the reason:

New Member Initiation Fee (Required)

How many new members are you adding today?

Price: $17.50

Total

Credit Card

Cardholder Name

Card Details