Name*:

Permanent Address:

Correspondence/ Office Address:

Contact No.:

E-mail ID*:

Date of Birth:

Age*:

Qualification*:

Current Occupation*:

Details of Job profile / Business:

Course last completed at Sky Academy:

Year and Batch :

Areas of Interest: Community ServiceInternational ServiceProfessional DevelopmentYouth ServiceClub Service

1. Will you take active part in the club’s social and service activites?: YesNo

2. Are you willing to pay the membership dues annually?: YesNo

3. The Rotary Foundation offers opportunities to Rotaractors ( who are not children or grandchildren of Rotarians) for study and travel abroad. Please indicate if you are a child or grandchild of a Rotarian.: Yes, I am.No, I am not.

Declaration : The above information submitted by me is correct and true to the best of my knowledge and belief. I, understand and accept the principles of Rotaract as expressed in its purpose and objectives and agree to comply with and be bound by the ‘Standard Rotaract Club Constitution ‘ , ‘Rotaract Statement of Policy’ and the by-laws of the said club.