First Name:       



Middle Name:   



Last Name:     



Address1:      



Address2:      



City           



State          



Zip/Postal     



Daytime Phone: 



Evening Phone: 



Fax Phone:     



Email Address: 

How would you like us to provide you information?



Surface Mail    



Telephone       



Email                 

Are you interested in joining a Kiwanis Club?



    YES 



    NO 



Are you a member of another community service club?



   YES



   NO



If YES, indicate club name?  



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