First Name:       

Middle Name:   

Last Name:     

Address1:      

Address2:      

City           

State          

Zip/Postal     

Country:       

Daytime Phone: 

Evening Phone: 

Fax Phone:     

Email Address: 

B>How would you like us to provide you information?

Surface Mail    

Telephone       

Email                 

Are you interested in joining a Kiwanis Club?

    YES 

    NO 

Are you a member of another community service club?

   YES

   NO

If YES, indicate club name?  

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