Candidate Name

Title

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First Name*

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Middle Name(s)

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Last Name*

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Suffix (Honours)

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Initials

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Nickname (will be known as)

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Gender

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Date of Birth*

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Partner (if applicable)

Partner first name

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Partner last name

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Contact Details

Home

Home Address*

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Home City*

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Home State*

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Home Post Code*

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PO Box Address (if applicable)

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Mobile

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Home Phone

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Personal Email address*

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Business

Organisation Name

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Occupation

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Current position held

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Business Address

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Business City

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Business State

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Business Post Code

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Business Phone

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Business E-mail address

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Business Website

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Communications

Preferred Email*

Home

Business

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Preferred Postal Address*

Home

Post

Business

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Other Membership Information

Other Rotary Clubs

I have been previously been a member of Rotary Club

Yes

No

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Previous Rotary Club details (including dates of membership)

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Other Organisation Memberships (non-Rotary)

Organisation name/s (including dates of membership)

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Rotary Melbourne Sponsor (if known)

Sponsor First Name

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Sponsor Last Name

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Working With Children

Working with Children Check Number*

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Expiry Date*

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Please Attach scan/photo of your WWC Card (Max 2MB)*

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Personal Statement

This personal statement below sets out (a) my reason(s) for wishing to join Rotary Club Of Melbourne, (b) a description of my vocation or profession and (c) what I may be able to contribute to the activities and projects of the Club.

Candidate's Personal Statement*

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If additional information (e.g. CV) is available to support this Expression Of Interest, please atttach it here.

Supporting documentation (Max 2MB)*

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Your Interests

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Please provide a personal photo (head & shoulders) (Max 2MB)*

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Commitment

Have you ever been charged with or found guilty of charges involving sexual, physical, or verbal abuse, including but not limited to domestic violence or intervention orders*

Yes

No

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If yes, please explain, and indicate date(s) of incident(s) and country and state in which each occurred. Charges that result in a diversion should be recorded, as should the final outcome of any intervention order applications which may have been made against you.

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Personal Undertakings

I, the undersigned, being familiar with the requirements for, and conditions of, membership as detailed in this document and contained in Constitution, hereby express an interest in seeking Active Membership of the Rotary Club Of Melbourne Inc. ("the Club").*

Yes

No

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I have applied for a Working With Children Check card endorsed as a volunteer with the Rotary Club of Melbourne Inc.*

Yes

No

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I understand that it will be my duty, if invited to join, to exemplify the Objects of Rotary International as detailed above in all my daily contact and activities, and, at all times, to abide by the, the Constitution of the Club.*

Yes

No

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I have read and understood the Membership Information Statement as supplied to me.*

Yes

No

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I agree to pay the above Entrance Fee and Annual Subscription (which will be pro-rated to reflect joining date) in accordance with the Rules of the Club following the completion of the Club’s membership formalities and prior to my induction into the Club.*

Yes

No

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I hereby give my permission to the Club to publish to its members my name, proposed classification and other above personal details as it deems appropriate.*

Yes

No

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I understand that the completion of this Membership Expression Of Interest Form confers no obligation on the Club to offer membership to me, nor any right of admission of me to membership of the Club.*

Yes

No

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I understand that the Club reserves the right to terminate its membership process related to me at any time prior to the final acceptance of me by the members of the Club.*

Yes

No

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I understand that part of my membership subscription includes an annual subscription to the official magazine or an approved and prescribed regional magazine as may be applicable.*

Yes

No

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If there is any matter in your biography that might affect your potential eligibility for active membership under the criteria set out above please disclose by attaching it in a separate document marked “confidential” addressed to the Chair of the Membership Review Committee. The Membership Review Committee will confidentially review the matter disclosed in all the circumstances to determine whether the matter affects present fitness for membership. Failure to disclose a relevant matter may itself be grounds for termination of membership.

Confidential Information Disclosure (Max 2MB)

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