"Connecting the World Through Service"

Membership Application

Thank you for applying to become a member of Civitan Connect! Please fill out the application below and click on the submit button.

Applicant's Name (*)

Please type your full name.
Mailing Address (*)

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Sponsor's Name (*)

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Home Telephone (*)

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Work Telephone

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Mobile Telephone

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E-mail (*)

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Other civic activities

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How should we contact you? (*)

When would you like to be contacted?

Please select a date when we should contact you.
Optional demographic information

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Spouse's Name (if applicable)

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Number of children

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Date of birth

Areas of Interest (Check all that apply)

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Additional Information

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I hereby request membership in Civitan Connect.  Upon acceptance, I agree to be subject to its bylaws and official policies.  I also agree to a one time initiation fee and dues payable to the club (options available listed below) which will cover Civitan International dues and insurance.

Option 1:  Standard:  Prepay Annual Dues with waived Initiation Fee $100.00 USD
Option 2:  Standard:  $25 Quarterly Dues plus $20 Initiation Fee $45.00 USD
Option 3:  Disabled or Student:  Prepay Annual Dues with waived Initiation $50.00 USD
Option 4:  Disabled or Student:  $12.50 Quarterly Dues plus $20 Initiation $32.50 USD

Once you click the submit button below you will be taken to a page where you can pay your initial dues and initiation fee (if applicable).

Validation (Type the number provided in the box below) (*)
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Your application will be transmitted to the club Secretary when you click the Submit button below.