DISTRICT 1100 WORKING IN PARTNERSHIP WITH DISTRICT 1160
EXPRESSION OF INTEREST
IN JOINING AN E-ROTARY CLUB
By completing and submitting this form you are expressing an interest in joining a Rotary e-club, initially this will be the Rotary EClub of District 1100, with a view to joining a new e-club in Ireland (D1160)
Full Name:
Date of Birth (optional):
Partner’s Name:
Telephone:
Home Address:
Mobile:
E-mail:
Social Networks:  Twitter
 Linked In
Postcode:
 Facebook
Other (state):
Business Name:
Position in Business:
Nature of Business:
Telephone:
Office Address:
E-mail:
Postcode:
Previous Rotary Club (if any):
Employment History (last 10 years)
Organisation
Position Held
From
To
Rotary Districts in
Great Britain &
Ireland
Voluntary/Community Service
Organisation
Position Held
From
To
Signature: ________________________________________________________
Date: ____/______/______
(Electronic signature acceptable)
Please email to rotary.eclub@btinternet.com or send to E-Rotary, The Secretary, c/o 23 Britten Road, Swindon, England, SN25 2HQ.
Data Privacy: Your details will be held by the Rotary E-Club of D1100 and will be used by Rotarians solely for the purpose of processing your interest in joining a Rotary E-Club and
will not be disclosed to any unauthorised third parties or sold for marketing purposes. All personal data will be destroyed upon successful application into membership of a Rotary
club/e-club or after 12’ months.
For Office Use Only Date Application Received: