Application Form

Membership Application

Membership Application

Choose an Option

New Member $120 quarterly

Rejoining this Club $120 quarterly

Transfer from Sertoma Club $120 quarterly

Friends of Sertoma $160 annually

Choose One

Mr.

Mrs.

Ms.

First Name

Last Name

Occupation

Job Title

Birthdate

Spouse

Recruited By

Home Address

Address 2

Address City

Address State

Address Zip Code

Home Phone

Email

Employer

Work Address

Work Phone

Work Email

Preferred Mailing Address

Home

Work

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