8/14/2019 New Member Add Form
1/1
Circle K International
3636 Woodview TraceIndianapolis, IN 46268 USA317/875-8755
e-mail: [email protected]
Membership BreakdownGender: Males _________
Females _________
Year: Freshman Members _________
Sophomore Members _________
Junior Members _________
Senior Members _________
Graduate Student Members _________
ease include the following information for each member of your
Circle K Club: name, graduation year, Male/Female (circle one),
permane
ailing address, telephone number and e-mail address. Please
attach additional sheets if necessary.
ay by check or money order. Do not mail cash. Include one copy
of completed membership form with duespayment. 10/2003
_______ New members X $25.00 (US) = $ ______________ New members
X $12.50(US = $ _______
_______ Total new members = $ _______
For new members joining after April 15
nternational Dues District Dues
_______ New members X $ _______ = $ ____________ New members X $
_______ = $ _____
_______ Total new members = $ ______
International/DistricNew Member Add Fo
INSTRUCTIONS:
Use this form for reporting new members only.
Use this form only if your club has paid dues previously during
the year.
If your club has not yet paid dues for any members, do not
submit this form, but instead submit the InternationInvoice and
Membership Forms. If you don not have these, call the Circle K
Inter national Office at (800) KIWA
and they will be sent to you. To ensure that Circle K
International has correct address information for club pres
and faculty advisors, it is important to submit the
International Dues Invoice and Membership Form first.
Extra copies of the New Member Add Form can be requested from
the Circle K International Office at (800) KIor you can make
photocopies of this blank form.
The second line in both the International and distr ict dues
sections refers to pro-rated dues. This applies only members
joining after April 15. Dues are pro-rated 50 percent for new
members on this date.
You must contact the Circle K District Administrator or the
Circle K International Office to find out dues amounyour district
and to whom in the district the payment should be sen t. Please do
not forget your district dues ob
Make all calculations, list all members and information
requested, and submit this form with a check for the proamount.
Combine district and International dues payments on one check.
Complete 3-part form and mail one copy to Circle K International
at the address above, one copy to the districin charge of district
dues, and keep one copy for the clubs files.(if applicable)
Name _____________________________________________ 6. Name
______________________________________
raduation Year: _________ M F Graduation Year: _________ M F
ddress: _____________________________________________ Address:
______________________________________
ity: ___________________ State: _____ Zip: _____________ City:
_________________ State: _____ Zip: ________
elephone #: _______________ E-mail: ____________________
Telephone #: _______________ E-mail: _____________
Name _____________________________________________ 7. Name
______________________________________
raduation Year: _________ M F Graduation Year: _________ M F
ddress: _____________________________________________ Address:
______________________________________
ity: ___________________ State: _____ Zip: _____________ City:
_________________ State: _____ Zip: ________
elephone #: _______________ E-mail: ____________________
Telephone #: _______________ E-mail: _____________Name
_____________________________________________ 8. Name
______________________________________
raduation Year: _________ M F Graduation Year: _________ M F
ddress: _____________________________________________ Address:
______________________________________
ity: ___________________ State: _____ Zip: _____________ City:
_________________ State: _____ Zip: ________
elephone #: _______________ E-mail: ____________________
Telephone #: _______________ E-mail: _____________
Name _____________________________________________ 9. Name
______________________________________
raduation Year: _________ M F Graduation Year: _________ M F
ddress: _____________________________________________ Address:
______________________________________
ity: ___________________ State: _____ Zip: _____________ City:
_________________ State: _____ Zip: ________
elephone #: _______________ E-mail: ____________________
Telephone #: _______________ E-mail: _____________
Name _____________________________________________ 10. Name
_____________________________________
raduation Year: _________ M F Graduation Year: _________ M F
ddress: _____________________________________________ Address:
______________________________________
ity: ___________________ State: _____ Zip: _____________ City:
_________________ State: _____ Zip: ________
elephone #: _______________ E-mail: ____________________
Telephone #: _______________ E-mail: _____________
embership Information - Club Name ____________________________
Key # _______________
