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Full Name __________________________________________________Nickname __________________________
Home address___________________________________________________________________________________
_______________________________________________________________________________________________
Home Phone___________________ Mobile Phone __________________ Spouse's Name_____________________
Name & Age of Children _________________________________________________________________________
College or University __________________________________________________ Degree ___________________
Occupation ___________________________________________ Title _____________________________________
Company Name_________________________________________________________________________________
Business Address ________________________________________________________________________________
_______________________________________________________________________________________________
Business Phone ___________________ Fax Number ___________________ E-mail_________________________
Send Kiwanis Mail to: Home _____ Work _____ Date of Birth ___________________________________
If you are a former Kiwanian: Club Name ___________________________________ Date Left ______________
Length of membership ______________ If you are a life member, life member # __________________________
Other Service Club Affiliations/Positions Held _______________________________________________________
Committee Preferences ___________________________________________________________________________
Induction Fee $150 Dues $260 per year (pro-rated)
Sponsor: ________________________________ Date Initiated: __________________________
Kiwanis Club of San Diego - 3276 Rosecrans, Suite 202 - San Diego, CA 92110
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