FELLOWSHIP OF LITERACY PROVIDERS
APPLICATION FOR MEMBERSHIP

NAME: ______________________________________________________
ROTARY CLUB: ______________________________________________
ROTARY DISTRICT: ___________________________________________
ROTARY CLASSIFICATION: ___________________________________
MAILING ADDRESS:
(Street)_______________________________________________________
(City)________________________________________________________
(State) _____________________________ (ZIP Code) ________________
(Country) _____________________________________________________
(Telephone #)__________________________________________________
(E-mail) ______________________________________________________

WOULD YOU LIKE TO SERVE ON A COMMITTEE? (YES) (NO)
CIRCLE AREA OF INTEREST:

VOCATIONAL TRAINING - COMPUTER ASSISTED LEARNING - JOB COUNSELING - TUTOR WORKSHOPS - HIGH SCHOOL DIPLOMAS -WORKPLACE LITERACY - RESOURCE MATERIALS - STUDY SKILLS -DIAGNOSTIC TESTING - ENGLISH AS A SECOND LANGUAGE -SCHOLARSHIP PROGRAMS - MENTORING PROGRAMS - ADULT EDUCATION - PRE-SCHOOL AGE CHILDREN - SCHOOL AGE CHILDREN -WOMEN EDUCATION (OTHER): ______________________________________________________

ANNUAL MEMBERSHIP DUES: US$20.00 PAY TO: Fellowship of Literacy Providers

MAIL CHECK AND APPLICATION TO: Fellowship of Literacy Providers
PDG Hal Shipley
P.O. Box 598
Clarksburg, CA USA 95612-0598

COMMENTS: (Literacy Involvement, Rotary Involvement, etc.)

 

Date:

Signature: