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Membership Application: Clubs Within Districts

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CLUBS WITHIN DISTRICTS

MEMBERSHIP APPLICATION For faster service, add and pay for your new members online at www.toastmasters.org/members Club Number: ____________________________ __________________________ __ District Number: __________ Club Name: __________________________________ _______________________________________________________ _____________________ City: __________ _________________________________________ _______________________________ Membership Type:

 New

 Reinstated (break in

 Transfer from  Transfer

membership)

 Renewing (no break in membership)

club number /name _______ /___________________

 Dual

Member Number (if known) __________

Chow Kok Kee _____________________________________________________________________________________________________

 Male

Last Name / Surname / Family Name

 Female

First Name / Given Name 

Middle Initial / Name

Suite 01-01 Menara IJM Land

______________________________________________________________________________________________________________________________ Address Line 1

No 1 Lebuh Tunku Kudin 3

______________________________________________________________________________________________________________________________ Address Line 2

Gelugor

Penang

Malaysia

11700

______________________________________________________________________________________________________________________________ City State/Province Country ZIP/Postal Code

0122085721

042961262

______________________________________________________________________________________________________________________________ Home Phone Number Mobile Number Work Phone Number

[email protected]

______________________________________________________________________________________________________________________________ Email  Please do

not send promotions to me from Toas Toastmasters tmasters International’s partners.

1. NEW MEMBER FEE . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . U.S. $20.00 Paid only by new members. Covers costs of the New Member Kit and processing.

$ ________

1a. California clubs add 7.75% sales tax ($1.55)

$ ________

2. Membership Dues (all members) Begin Date ______________________________ Month/Year   Pro-rated at $6.00 per month.  October   November  December  January  February  March

or or or or or or

 April  May  June  July  August  September

U.S. $36.00 30.00 24.00 18.00 12.00 6.00

3. Total of 1, 1a, and 2

$ ________

New Member Kit preference for new members only:  English  French  Spanish  Japanese  Chinese (Traditional)  Chinese (Simplified)  German  Arabic  PDF on CD

$ ________

  (visually impaired only) Selected materials in the new member kit are available in English only.

PA PAYMENT YMENT INFORMATION   Choose one: Check or money order in U.S. funds drawn on a U.S. bank, or credit card payment, must be included. Line 3 is the amount payable to Toastmasters International. Note:  Your club may also char charge ge dues to meet club expenses. Unfortunately, Unfortunately, WHQ is unable to charge club dues on the credit card submitted. Club dues must be paid directly to the club. Dues and fees are payable in advance and are not refundable or transferable.  Check:

No. ____________________

 Credit Card:

 MasterCard

 Visa

Amount $ ________________________

 AMEX

 Discover

Club Dues Worksheet FOR CLUB USE ONLY

International fees and dues: (from Line 3 on left)

$_______

Card No. No. _________________________________________ Exp. Date ________________

Club New Member Fee:

_______

Signature / Name on Card ____________________________________________________

Club Dues:

_______

 Other __________________________________________________________________

 Total:

$_______

 

recruited and/or encouraged the member to join. New / Reinstated / Dual Member Sponsor:  The person who recruited ________________________________________________________________________________________________________________ Last Name / Surname / Family Name First Name / Given Name Middle Initial / Name ________________________________________________________________________________________________________________ Sponsor’s District Number Sponsor’s Home Club Number Member Number (if known) NOTE: TO ENSURE PROPER CREDIT, THE SPONSOR’S FULL FIRST AND LAST NAME AND HOME CLUB NUMBER MUST APPEAR.

Member’s Agreement and Release:

Consistent with my desire to take personal responsibility for my conduct, individually and as a member of a Toastmasters Toastmasters club, I agree to abide by the principles contained in “A Toastmaster’s Promise” and the governing documents and policies of Toastmasters International and my club. I will refrain from any form of discrimination, harassment, derogatory, illegal, or unethical conduct, and I understand that if I engage in such conduct, I may be responsible to reimburse Toastmasters International, International, my club or other clubs, or other individuals involved with Toastmasters, Toastmasters, for any damages, losses, or costs resulting from my conduct. Understanding that Toastmasters Toastmasters programs are conducted by volunteers who cannot be effectively screened or supervised by Toastmasters Toastmasters International or its clubs, I release and discharge Toastmasters Toastmasters International, its clubs, governing bodies, and representatives from any liability for the intentional or negligent acts or omissions of any member or officer of my club or other clubs, or any officer of Toastmasters Toastmasters International. By submitting this application, I agree to the collection, use and processing of the personal information I provide to Toastmasters Toastmasters in this Membership Application for the purposes of organization administration, payment of my dues, and inclusion of my contact information in a members’ directory directory that will be distributed to members and employees of Toastmasters. By submitting my personal information to Toastmasters, Toastmasters, I also agree that my information may be accessed and used by Toastmasters Toastmasters and its employees and agents, and will be transferred to countries that are not regarded as having adequate data protection, including to Toastmasters’ Toastmasters’ headquarters in the United States. I agree to notify [email protected] of any change to my personal information, including making any requests to check, delete or correct my personal information, so that it is accurate and current. I understand that the majority of the data requested in this application a pplication is necessary for administrative and planning purposes, and that the failure to provide this information may prevent my application from being properly processed or inclusion of my contact information in the members’ directory.

A Toastmast Toastmaster’s er’s Promise

As a member of Toastmasters International and my club, I promise... `  To attend

club meetings regularly; regularly;

`  To prepare

all of my speech speech and leadership projects to the best of my ability, basing them on projects in the Competent Communication,  Advanced Communica Communication tion or Competent Leadership manuals;

`  To prepare

for and fulfill meeting assignments;

`  To provide

fellow members members with helpful, conconstructive evaluations;

`  To help

the club maintain the positive, friendly environment necessary for all members to learn and grow;

`  To serve

to do so;

my club as an officer when called upon

`  To treat

my fellow club members and our guests with respect and courtesy;

`  To bring

guests to club meetings meetings so they can see the benefits Toastmasters Toastmasters membership offers;

`  To adhere

to the guidelines and and rules for all  Toastmasters educational and recognition  Toastmasters programs;

`  To maintain

honest and highly ethical standards during the conduct of all Toastmasters Toastmasters activities.

I confirm that a completed new member application for this member is on file with the club and will be retained by the club. The application contains both the signature of the new member and the signature of a club officer. Questions Questions should be directed to the Membership department: [email protected] By my signature below, I agree to the terms of  A Toastmaster’s Toastmaster’s PromPromise, and the Indemnifi Indemnification cation and Release  stated above, and certify that I am 18 years of age ag e or older, in compliance with the Toastmasters International Club Constitution. I acknowledge that my electronic signature on this document is legally equivalent to my hand-written signature. Signed: ________________________________________________ A P P L I CA N T

By my signature below, I certify that this individual has joined the  Toastmasters  To astmasters club identified. As a club, we will ensure that this member receives proper orientation and mentoring. I acknowledge that my electronic signature on this document is legally equivalent to my hand-written signature.

Signed: ________________________________________________ CLUB OFFICER

In order for this application to be valid both signatures are required.

CLUB OFFICER – Please keep a copy for your club’s records. If paying online, go to www.toastmasters.org/members , and log in. If mailing, send to: Membership Records, Toastmasters Toastmasters International, P.O. P.O. Box 9052, Mission Viejo, CA 92690 USA. If faxing, send to: 949-858-1207. 949-858-1207. Note: Please submit information via one method only to avoid du plication. For fastest results, enter new members online. Rev 6/2011

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