KIWANIS CLUB

KIWANIS MEMBERSHIP INFORMATION

KEY NUMBER DISTRICT NAME OR NUMBER STATE/PROVINCE

PLEASE TYPE OR PRINT

COUNTRY

MEMBERSHIP ID NUMBER MULTIPLE MEMBERSHIP

PLEASE CHECK ONE NEW OR FORMER MEMBER ADD MEMBER INFORMATION CHANGE

KIWANIS LIFE MEMBER

MEMBER DELETE HONORARY MEMBERSHIP NO

YES

KIWANIS LIFE MEMBER NUMBER MEMBER ID NUMBER

MEMBER TRANSFER NON-MEMBER SUBSCRIPTION YES NO

DISTRICT LIFE MEMBERSHIP

YES

NO

IF YES, CLUB NAME

KEY NUMBER SUFFIX

DATE JOINED (MONTH/DAY/YEAR) MIDDLE INITIAL PREFIX

LAST NAME GENDER DATE OF BIRTH TELEPHONE

FIRST NAME PREFERRED EMAIL ADDRESS

M F

HOME ADDRESS BUSINESS NAME CITY SPOUSE NAME

CITY TITLE/POSITION STATE/PROVINCE COUNTRY

STATE/PROVINCE BUSINESS ADDRESS

COUNTRY

ZIP/POSTAL CODE

ZIP/POSTAL CODE FAX NUMBER

BUSINESS PHONE KEY NUMBER MEMBER ID NUMBER SPOUSAL MAGAZINE CREDIT

IS SPOUSE A MEMBER IF YES, CLUB NAME

YES

NO

SEND KIWANIS MAIL TO: l HOME

PRIMARY EMPLOYMENT Codes
1 3 5 7 9 Banking/Finance Communications/Media Construction Education Government 11 13 15 17 19

l WORK

CHECK ONE BLOCK PER CATEGORY

Legal Manufacturing (Heavy) Manufacturing (Light) Medical Nonprofit A B C D E 21 23 25 27 29 Real Estate Religion Retail Transportation Wholesale

YES

NO

31 Agriculture 94 Other ____________________

JOB CLASSIFICATION Codes

N Elected O Management P Partner/Owner Q Professional R Sales

S Supervision T Technical V Retired X Other _____________________

EDUCATION ATTAINED Codes

Grade School High School Technical/Business School Associate Degree (2 yrs) Baccalaureate Degree (4 yrs)

F Masters Degree G Graduate Professional Degree H College/University Attended

New member sponsored by: Name __________________________________________________________ID Number_________________________________ 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
PLEASE NOTE: FOR MEMBERSHIP STATISTICS ONLY. KIWANIS INTERNATIONAL DOES NOT PROVIDE MEMBERSHIP INFORMATION TO THIRD PARTIES.

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 _________________________________ 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 (Date)