Required fields are marked with a red asterisk *. Membership Type * I am a new member. I am renewing an existing membership. First Name * Last Name * Title/Occupation Employer Home Address Street 1 Street 2 City State Zip Phone * Email * Business Address Street 1 Street 2 City State Zip Email Phone Date of Birth Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year If you are a new member, what prompted you to join? Friday Forum New Leaders Council event Agora event Citizen Salon Serve on an event committee (Agora, NLC, Friday Forum) Serve on a research committee A friend/colleague suggested it My employer asked me to join or gave me a membership I’m new to town To learn about my community Social media source News source Other Please check as many as apply. If a person referred you to City Club, please tell us who Preferred Email Address Home Business Preferred Postal Mail Address Home Business City Club publishes member names and contact information on our website with their permission. Would you like to be included in this list? Yes No Public InformationYou may choose one or all of the fields – every field is optional. Name Job Employer Phone Email
