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 Preferred Email(Required)

New Member Preferred Phone

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, type and reason:

Do you need to add a second new member?

Yes

New #2 Member Name(Required)

First Last

New Member #2 Preferred Email(Required)

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, type and reason:

Do you need to add a third new member?

Yes

New Member #3 Name(Required)

First Last

New Member #3 Preferred Email(Required)

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, type and reason:

Do you need to add a fourth new member?

Yes

New Member #4 Name(Required)

First Last

New Member #4 Preferred Email(Required)

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, type and reason:

Do you need to add a fifth new member?

Yes

New Member #5 Name(Required)

First Last

New Member #5 Preferred Email(Required)

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, type and reason:

Payment Information

New Member Initiation Fee (Required)

How many new members are you adding today?

Price: $22.50

Total

Credit Card

Cardholder Name

Card Details