Kiwanis Membership Form - Redmond Kiwanis
KIWANIS MEMBERSHIP INFORMATION
KIWANIS CLUB
PLEASE CHECK ONE NEW OR FORMER MEMBER ADD MEMBER INFORMATION CHANGE
MEMBERSHIP ID NUMBER MULTIPLE MEMBERSHIP
YES
NO
MEMBER DELETE HONORARY MEMBERSHIP
KIWANIS LIFE MEMBER
YES
IF YES, CLUB NAME
M F
SUFFIX DATE OF BIRTH
STATE/PROVINCE
YES
Banking/Finance Communications/Media Construction Education Government
STATE/PROVINCE
COUNTRY
ZIP/POSTAL CODE FAX NUMBER
NO
ZIP/POSTAL CODE
BUSINESS PHONE
SPOUSAL MAGAZINE CREDIT
Legal Manufacturing (Heavy) Manufacturing (Light) Medical Nonprofit
S Supervision T Technical V Retired X Other _____________________
COUNTRY
KEY NUMBER MEMBER ID NUMBER
CHECK ONE BLOCK PER CATEGORY 11 13 15 17 19
PREFIX
BUSINESS ADDRESS
l WORK
JOB CLASSIFICATION Codes N Elected O Management P Partner/Owner Q Professional R Sales
MIDDLE INITIAL
IS SPOUSE A MEMBER IF YES, CLUB NAME
PRIMARY EMPLOYMENT Codes
NO
DATE JOINED (MONTH/DAY/YEAR)
FIRST NAME
TITLE/POSITION
SEND KIWANIS MAIL TO: l HOME
YES
PREFERRED EMAIL ADDRESS
BUSINESS NAME
SPOUSE NAME
DISTRICT LIFE MEMBERSHIP
MEMBER ID NUMBER
CITY
CITY
COUNTRY
MEMBER TRANSFER NON-MEMBER SUBSCRIPTION
KIWANIS LIFE MEMBER NUMBER
TELEPHONE
HOME ADDRESS
1 3 5 7 9
NO
KEY NUMBER
LAST NAME GENDER
PLEASE TYPE OR PRINT
KEY NUMBER DISTRICT NAME OR NUMBER STATE/PROVINCE
21 23 25 27 29
Real Estate Religion Retail Transportation Wholesale
EDUCATION ATTAINED Codes A B C D E
Grade School High School Technical/Business School Associate Degree (2 yrs) Baccalaureate Degree (4 yrs)
YES
NO
31 Agriculture 94 Other ____________________
F Master’s Degree G Graduate Professional Degree H College/University Attended
New member sponsored by: Name __________________________________________________________ID Number_________________________________ PLEASE NOTE: FOR MEMBERSHIP STATISTICS ONLY. KIWANIS INTERNATIONAL DOES NOT PROVIDE MEMBERSHIP INFORMATION TO THIRD PARTIES.
If you are a former member Kiwanis Key Club Kiwanis Junior Circle K Aktion Club K-Kids Builders Club Club Name __________________________________________________ Former ID Number _______________________________ Date Joined __________________________________________________ Date Left _______________________________________ PLEASE COMPLETE THIS SECTION ONLY IF DELETING A MEMBER Effective date (MM/DD/YYYY) __________________________ Check reason for delete - Codes A Attendance H Health
B Business Pressure I Lack of interest
D Deceased L Lack of time
G Other_______________________ M Moving P Non payment of dues
PLEASE COMPLETE THIS SECTION ONLY IF MEMBER IS TRANSFERRING TO ANOTHER KIWANIS CLUB Effective Date (MM/DD/YYYY) ________________________________ Dues paid through _________________________________ (Date)
Club transferring to - Club Name ______________________________ Key Number _________________ District ______________ NOTE: PLEASE GIVE ONE COPY OF THIS FORM TO MEMBER TO BE GIVEN TO THE CLUB TO WHICH HE OR SHE IS TRANSFERRING. White-Kiwanis International, Attn: Member Services, 3636 Woodview Trace, Indianapolis, IN 46268
Canary-District Office
Green-Club File
KIWANIS CLUB
PLEASE CHECK ONE NEW OR FORMER MEMBER ADD MEMBER INFORMATION CHANGE
MEMBERSHIP ID NUMBER MULTIPLE MEMBERSHIP
YES
NO
MEMBER DELETE HONORARY MEMBERSHIP
KIWANIS LIFE MEMBER
YES
IF YES, CLUB NAME
M F
SUFFIX DATE OF BIRTH
STATE/PROVINCE
YES
Banking/Finance Communications/Media Construction Education Government
STATE/PROVINCE
COUNTRY
ZIP/POSTAL CODE FAX NUMBER
NO
ZIP/POSTAL CODE
BUSINESS PHONE
SPOUSAL MAGAZINE CREDIT
Legal Manufacturing (Heavy) Manufacturing (Light) Medical Nonprofit
S Supervision T Technical V Retired X Other _____________________
COUNTRY
KEY NUMBER MEMBER ID NUMBER
CHECK ONE BLOCK PER CATEGORY 11 13 15 17 19
PREFIX
BUSINESS ADDRESS
l WORK
JOB CLASSIFICATION Codes N Elected O Management P Partner/Owner Q Professional R Sales
MIDDLE INITIAL
IS SPOUSE A MEMBER IF YES, CLUB NAME
PRIMARY EMPLOYMENT Codes
NO
DATE JOINED (MONTH/DAY/YEAR)
FIRST NAME
TITLE/POSITION
SEND KIWANIS MAIL TO: l HOME
YES
PREFERRED EMAIL ADDRESS
BUSINESS NAME
SPOUSE NAME
DISTRICT LIFE MEMBERSHIP
MEMBER ID NUMBER
CITY
CITY
COUNTRY
MEMBER TRANSFER NON-MEMBER SUBSCRIPTION
KIWANIS LIFE MEMBER NUMBER
TELEPHONE
HOME ADDRESS
1 3 5 7 9
NO
KEY NUMBER
LAST NAME GENDER
PLEASE TYPE OR PRINT
KEY NUMBER DISTRICT NAME OR NUMBER STATE/PROVINCE
21 23 25 27 29
Real Estate Religion Retail Transportation Wholesale
EDUCATION ATTAINED Codes A B C D E
Grade School High School Technical/Business School Associate Degree (2 yrs) Baccalaureate Degree (4 yrs)
YES
NO
31 Agriculture 94 Other ____________________
F Master’s Degree G Graduate Professional Degree H College/University Attended
New member sponsored by: Name __________________________________________________________ID Number_________________________________ PLEASE NOTE: FOR MEMBERSHIP STATISTICS ONLY. KIWANIS INTERNATIONAL DOES NOT PROVIDE MEMBERSHIP INFORMATION TO THIRD PARTIES.
If you are a former member Kiwanis Key Club Kiwanis Junior Circle K Aktion Club K-Kids Builders Club Club Name __________________________________________________ Former ID Number _______________________________ Date Joined __________________________________________________ Date Left _______________________________________ PLEASE COMPLETE THIS SECTION ONLY IF DELETING A MEMBER Effective date (MM/DD/YYYY) __________________________ Check reason for delete - Codes A Attendance H Health
B Business Pressure I Lack of interest
D Deceased L Lack of time
G Other_______________________ M Moving P Non payment of dues
PLEASE COMPLETE THIS SECTION ONLY IF MEMBER IS TRANSFERRING TO ANOTHER KIWANIS CLUB Effective Date (MM/DD/YYYY) ________________________________ Dues paid through _________________________________ (Date)
Club transferring to - Club Name ______________________________ Key Number _________________ District ______________ NOTE: PLEASE GIVE ONE COPY OF THIS FORM TO MEMBER TO BE GIVEN TO THE CLUB TO WHICH HE OR SHE IS TRANSFERRING. White-Kiwanis International, Attn: Member Services, 3636 Woodview Trace, Indianapolis, IN 46268
Canary-District Office
Green-Club File
