Electronic Membership Application Form

Hometown Civitan Club & Hometown Charities, Inc.
Electronic Membership Application

Applicant's Name

Mailing Address: Street, Village/City, Zip Code

E-mail Address

Primary Phone Number

Retired/Business Name

Birthday: Month/Day

Applicant Sponsor's Name

1. Service Projects

2. Community Projects

3. Social Activities

4. Administrative Support

I hereby request membership in the Hometown Civitan Club. Upon acceptance, I agree to be subject to its by-laws and official policies.

I also agree to pay any dues to the club, region and Civitan International, as billed by the club (currently $150 per year).

By submitting this application electronically, my signature and date of application are confirmed.

I request that my personal information be used solely for communication within this club, region and Civitan International headquarters.

Thanks for submitting!