Membership Form

Personal Information

Full Name

Nickname

Gender

Primary Date of Birth

Email Address

Spouse/Partner's Name

Street Address

City

State

Zip Code

Phone Number

Business Information

Company Name

Business Title

Business Address

Business Phone Number

Fax Number

Business Email Address

Primary Employment

Job Classification

Education Attained

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I am a former Kiwanis Member

Kiwanian Information Information

If you're a Former Kiwanian:Club Name

Date Left Club

Length of Membership

Life Member Number

Committee Preference

Current Date

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