Kiwanis International Membership Application

Date: *

Club Applying To: *

Personal

Full Name *

Nickname

Gender *

Date of Birth *

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 *

Job Classification *

Education Attained *

Kiwanis

Send Kiwanis mail to: *

Prefered phone for Kiwanis contact *

Life Member Number (if applicable)

Former Club Name (if applicable):

Length of Membership:

Date left:

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