Application for Membership

Kiwanis Membership Information


Full Name: Nickname:
Gender: Male    Female
Home Address Information
Street Address: City:   State:   Zip:
Phone: Spouse / Partner Name:
Business Information
Company Name: Title
Street Address: City:   State:   Zip:
Phone: Fax:
Email Address:
Send Kiwanis mail to: Home    Work
If you are a former Kiwanian:
Club Name: When you Left (month/day/year):
Length of Membership (years): If you are a Lifetime Member, Life Member #:
Date of Birth (month/day/year): Committee Preference: Club Administration
Community Service