The Kiwanis Club of North London

Applicant Information

Full Name: ________________________________________________________

Spouse's Name: ________________________________________________________

Gender: F _____ M _____

Home Address: Street and Number: ______________________________________

City: ______________________________________

Postal Code: ______________________________________

E-mail Address: ______________________________________

Telephone: Home: ________________ Business: _____________

Are You a Former Kiwanis Member? Yes _____ No _____

Club Name: ____________________________________________

Date Left: (dd/mm/yyyy) __________________________

Length of Membership: ________________________________

Life Membership Number: ________________________________

Date of Birth: (dd/mm/yyyy) ______________________________________

Please forward completed form to the contact person on our "Contact Us" web page.