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Rotarian (US$225)

* First Name:

* Last Name:

Call Name:

* District:

* Rotary Club:

Year Gov:

Year Dir:

Year RI Pres:

* Address:

* City:

* State:

* Zipcode:

* Country:

* Home Phone:

Fax:

* Email:

Partner/Spouse (US$125)

Leave blank if not registering a Partner/Spouse.

First Name:

Last Name:

Call Name:

Rotarian

Rotary Club:

Confirmation and Payment

When submitting this form, you will see a confirmation screen with the calculation of the Conference fee, and you will be able to pay online. Payment may also be sent by mail. Registration will not be complete until you select a payment option.

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