Rotary Foundation

ALUMNI

Rotary International Districts
9550, 9570, 9600, 9630 and 9640
Covering Queensland and Far Northern
New South Wales

Information Update Form

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This information will be used for Rotary and Foundation Alumni purposes only and will not under any circumstance be made available outside of Rotary circles.

I am providing:	Initial InformationUpdate to existing Information
Family Name (Surname)
Family Name at time of Award
Given or First Name/s
Street Address
City
State or Province
Zip or Postal Code
Country
Home Telephone
Business Telephone
Fax
E-mail
Foundation Alumni ID (if known)
Sponsor Club
Host Club
Sponsor District
Host District
Sponsor Country
Host Country
Date the Award Started
Date the Award Completed
Institution attended
Area of Study or Research
Qualification Attained
Other Personal Information
Your present Job Title
Your present employer
Rotary Involvement (tick those that apply)
Rotary Foundation Scholar
Rotary Peace Fellow
GSE team member
Rotary Volunteer
University Teacher
Carl P. Miller Discovery Grant team member

Additional Questions
Are you a Rotarian?	yes no
If yes, which club?
If yes, which District?
If yes, Rotary Membership Number (if available)
If no, have you been invited to become a Rotarian?	yes no
Would you like to be invited?	yes no
Are you available to be a Guest Speaker?	yes no
Would you like to receive the Alumni Newsletter on-line?	yes no
Do you have you any other comments?