New Member Information

Name*

First Last

Nickname

First

Email*

Enter Email Confirm Email

Cell Phone*

Home Phone

Optional

Address*

Street Address Address Line 2 City State ZIP Code

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Gender*

Male
Female

Birthdate*

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Spouse/Partner Name

First Last

Spouse/Partner Birthdate

Wedding Anniversary Date

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Corporate Membership?*

Yes
No

Are you joining as an individual or as a corporation and you are its representative.

Company Name

Title

Business Email

Enter Email Confirm Email

Business Phone

Business Address

Street Address Address Line 2 City State ZIP Code

Send Kiwanis Email to

Home Email Address
Business Email Address

Send Kiwanis Mail to

Home Address
Business Address

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Are you a former Kiwanian?*

Yes
No

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Sponsor's Name

Who is the person that brought you into the Club?

First Last

Date of Form*

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