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Kiwanis International Membership Application
Date:
*
+
Club Applying To:
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Bonita (Fort Myers-Edison satellite)
Cape Coral
Fort Myers
Fort Myers Beach
Fort Myers Edison
Gateway
Greater Pine Island
LaBelle
Lehigh Acres
Metro-McGregor
San Carlos Park Estero
Sanibel Captiva Island
Personal
Full Name
*
Nickname
Gender
*
Female
Male
Date of Birth
*
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Spouse/Partner
Street Address
*
City
*
St
*
ZIP Code
*
Main Phone
*
🛈
Alt. Phone
🛈
Business Information
Company Name
Your Title
Bus. Address
State
Bus. ZIP
Bus. Phone
🛈
Fax
Email Address
Primary Employment
*
Banking/Finance
Comm/Media
Construction
Education
Government
Manufact. (Light)
Medical
Real Estate
Religion
Retail
Transportation
Wholesale
Other
Job Classification
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Elected
Management
Partner/Owner
Professional
Sales
Supervision
Technical
Retired
Education Attained
*
Grade School
High School
Tech./Business School
Assoc. Degree (2 yrs)
Bachelor's Degree (4 yrs)
Master's Degree
Grad. Prof. Degree
Kiwanis
Send Kiwanis mail to:
*
Home
Business
Prefered phone for Kiwanis contact
*
Main
Alternate
Business
Life Member Number (if applicable)
Former Club Name (if applicable):
Length of Membership:
Date left:
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