Institute for Leadership Event
April 24, 25 2015
Applicaction
Name: _____________________________________________________ Gender: Male Female
Rotary Club of: ________________________________________________________________
Home Address:
______________________________________________________________________________
City: _________________________________ State: ________________ Zip Code: __________
Business Address:
______________________________________________________________________________
City: _________________________________ State: ________________ Zip Code: __________
Business Telephone: ____________________________ Residence Telephone ______________
Fax Number: ___________________________________________________________________
Email address: _________________________________________________________________
The total fee, that includes materials and five meals, is $150.00
Attached is my check for $50.00 made out to The Rotary Club of El Paso
to reserve my place.
Signature of the Rotarian: __________________________________ Date: ___________
SUBMIT COMPLETED APPLICATION TO
Mr. Mike Adkins
100 South Alto Mesa, El Paso, Texas 79912
By April 15, 2015
If you have any questions please call Mike Adkins at 915-479-7181 or
Sonny Brown 915-241-1525