YES! I would like to join ESRAG (Information provided will be used strictly for ESRAG use unless otherwise instructed)

Applicants are asked to complete the following information. Starred items(*) are required. After completing this form, click ‘Submit’. A copy of this application will be emailed to you. Or you can also print this form and mail it to the address below.

Member Information:

* First Name:
* Last Name:
* Email Address	This email is already in the system. Please email membership at [email protected] to change your membership type.
* Are you a:	Rotarian Rotaractor Non-Rotarian
* Club Country:
* State/Province:
* Club Name:

Billing Address:

* Address1:	(Address)
Address2:	(Ste/Suite)
* City:
State Code:
Province:
Country Code:
*Postal Code:
Captcha Code:

ESRAG and our membership management system vendor, Member Minder Pro, LLC, dba iMembersDB, is collecting your personal information in order to process your online application for ESRAG membership. The Registrant authorizes ESRAG to collect and use personal information about the Registrant for the purpose of receiving communications and the purposes described in the ESRAG policies relating to data privacy - esrag.org/privacy. Permission may be withdrawn at any time by contacting ESRAG’s Privacy Officer at [email protected]. Please check the "I Consent" checkbox below to allow us to collect, use, and disclose your personal information as described above.

I Consent