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CLUBS WITHIN DISTRICTS

MEMBERSHIP APPLICATION

Club InformationThis section is completed by a club officer.

_________________________________________________________________________________________

Club number Club name Club city

Applicant InformationThis section is completed by the applicant.

_________________________________________________________________________________________Last name/Surname First name Middle name

The monthlyToastmastermagazine will be sent to the following address:

_____________________________________________________________________Company/In care of

_____________________________________________________________________Address line 1 (limit 35 characters)

_____________________________________________________________________

Address line 2 (limit 35 characters)

_____________________________________________________________________City State or province

_____________________________________________________________________Country Postal code

_______________________________________________________________________________________________________________________________________Home phone number Mobile phone number Email address

MaleFemale

Payment to Toastmasters InternationalThis section is completed by the applicant with the help of a club officer.Dues and fees are payable in advance and are not refundable or transferable.

New member fee (US$20) US$ __________Paid only by new members, this fee covers the cost of theNew Member Kit and processing.

California sales tax (US$1.60) US$ __________Paid only by members of California clubs, sales tax is 8%.Membership dues US$ __________Paid twice a year by all members, membership dues arepro-rated from the members start month at US$6 per month:

October: US$36

November: US$30

December: US$24

January: US$18

February: US$12

March: US$6

April: US$36

May: US$30

June: US$24

July: US$18

August: US$12

September: US$6

I want my membership to begin ______________________________________ Month Year

Total payment to Toastmasters International US$ __________Add the new member fee, California sales tax (if applicable),and membership dues to determine the amount payable to

Toastmasters International.

Payment to ClubThis section is completed by the applicant with the help of a club officer. Club duesmust be paid directly to the club. World Headquarters cannot charge credit cardpayments for club dues.

Club new member fee US$ __________

Club dues US$ __________

Total payment to club US$ __________

Payment MethodThis section is completed by the applicant.

MasterCard

Visa

AMEX

Discover

Check or money order

Check or money ordermust be for U.S. fundsdrawn on a U.S. bank.

Other

US$ ___________________________________Amount

______________________________________Card number

______________________________________Expiration date

______________________________________Name on card

______________________________________Signature

US$ ___________________________________Amount

______________________________________Check or money order number

______________________________________Other

Membership TypeThis section is completed by a club officer.

New

Dual

Transfer (If applicantis transferring fromanother club, pleasefill in the three linesbelow.)

Reinstated (break inmembership)

Renewing (no break inmembership)

_______________________________________Previous club name

_______________________________________Previous club number

_______________________________________Member number

New Member Kit Preference

This section is completed by the applicant if a new member.

English

Franais

Deutsch

Espaol

Portugus Accessible PDF on CD

for the visuallyimpaired (English only)

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Sponsor of New, Reinstated or Dual MemberThis section is completed by a club officer.

_______________________________________________________________________________________________________________________________________Sponsors last name/surname Sponsors first name Sponsors member number Sponsors club number

Members Agreement and ReleaseConsistent with my desire to take personal responsibility for my conduct, individuallyand as a member of a Toastmasters club, I agree to abide by the principles contained inA Toastmasters Promise and the governing documents and policies of ToastmastersInternational and my club. I will refrain from any form of discrimination, harassment,bullying, derogatory, illegal, or unethical conduct, and I understand that if I engagein such conduct, I agree to reimburse Toastmasters International, my club or otherclubs, or other individuals involved with Toastmasters, for any damages, losses or costsresulting from my conduct. Understanding that Toastmasters programs are conductedby volunteers who cannot be effectively screened or supervised by ToastmastersInternational or its clubs, I release and discharge Toastmasters International, its clubs,governing bodies, officers, employees, agents, and representatives from any liability forthe intentional or negligent acts or omissions of any member or officer of my club orother clubs, or any officer of Toastmasters International.

By submitting this application, I agree to the collection, use and processing of thepersonal information I provide to Toastmasters in this membership application for the

purposes of organization administration, payment of my dues, and inclusion of mycontact information in a members directory that will be distributed to members andemployees of Toastmasters. By submitting my personal information to Toastmasters, I alsoagree that my information may be accessed and used by Toastmasters and its employeesand agents. I agree to notify addresschanges@toastmasters.orgof any change tomy personal information and make requests to check, delete or correct my personalinformation, so that it is accurate and current. I understand that the majority of the datarequested in this application is necessary for administrative and planning purposesand that the failure to provide this information may prevent my application from beingproperly processed or the inclusion of my contact information in the members directory.

A Toastmasters PromiseAs a member of Toastmasters International and my club, I promise

To attend club meetings regularly

To prepare all of my speech and leadership projects to the best of my ability,

basing them on projects in the Competent Communication, Advanced

Communicationor Competent Leadershipmanuals

To prepare for and fulfill meeting assignments

To provide fellow members with helpful, constructive evaluations

To help the club maintain the positive, friendly environment necessary for all

members to learn and grow

To serve my club as an officer when called upon to do so

To treat my fellow club members and our guests with respect and courtesy

To bring guests to club meetings so they can see the benefits Toastmasters

membership offers

To adhere to the guidelines and rules for all Toastmasters education and

recognition programs

To maintain honest and highly ethical standards during the conduct of all

Toastmasters activities

Verification of ApplicantBy my signature below, I agree to the terms of A Toastmasters Promise and the MembersAgreement and Release stated above and certify that I am 18 years of age or older, incompliance with the Toastmasters Club Constitution for Member Clubs of ToastmastersInternational.

I acknowledge that my electronic signature on this document is legally equivalent to myhandwritten signature.

Verification of Club OfficerI confirm that a complete membership application, including both the signature of the newmember and that of a club officer, is on file with the club and will be retained by the club.

By my signature below, I certify that this individual has joined the Toastmasters clubidentified. As a club, we will ensure that this member receives proper orientation andmentoring.

I acknowledge that my electronic signature on this document is legally equivalent to myhandwritten signature.

_______________________________________________________________________________________________________________________________________Applicants signature Club officers signature

In order for this application to be valid, both signatures are required.

Application Process

Applications are submitted by a club officer and can be submitted online by logging in to www.toastmasters.org/clubcentral. Otherwise, mail the application toMembership, Toastmasters International, P.O. Box 9052, Mission Viejo, CA 92690, U.S.A., or fax to +1 949-858-1207.

Please use only one method to submit this information in order to avoid duplication.

Contactmembership@toastmasters.orgwith any questions.

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