Club Number: K14257
NAME:
NICKNAME:
ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME PH#:
CELL PH#:
FAX #:
EMAIL:
BUSINESS NAME:
BUSINESS ADDRESS:
BUSINESS PH#:
If not a full-time resident, indicate months away: (tick months away)
JANFEBMARAPRMAYJUNJULAUGSEPTOCTNOVDEC
Send my Kiwanis mail to: Home:Business:
Birthday M/D:
Anniversary M/D:
Spouse’s Name:
Who sponsored you into the club:
Are you a former Kiwanian: Yes:No:
Club:
Date left:
Length of membership:123456789101112131415161718192020+
Officer:
Perfect attendance:Yes:No:
I agree to conform to the By-Laws of the Kiwanis Club of Marco Island.
