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Service Provider Registration

We, _______________________________, apply for CBO / FBO Service Provider with the Brick City Rotary Club of Newark NJ and authorize consideration by the Club’s Board of Directors. If approved by the Board, we authorize publication of our organization’s name and designees to the Club’s Honorary membership roster.
We value the important work of your organization and invite you to partner with us as a Community-Based or Faith-Based Service Provider. There is no cost to join — only a shared commitment to uplifting our Newark community.

Name of Organization *

Organization Business Information

Name *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone *

Website *

Image UploadPlease upload your organization logo for our partners records.

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Primary Organization Designee Information

Name *

Title *

Birthday *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Preferred Phone Number *

Preferred Email Address *

Critical Determinant Focus *

Primary Services Provided *

Primary Cohort *

Personal Interest(s) *

Organization Interest(s) *

Do you want to enroll in Magazine Newsletter? *

How would you like to receive the magazine? *DigitalPhysical

Alternate Organization Designee(s)

How many alternate designees do you want to add? *123

Alternate Designee 1

Name *

Title *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone *

Email Address *

Alternate Designee 2

Name *

Job Title *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone *

Email Address *

Alternate Designee 3

Name *

Job Title *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone *

Email Address *

Membership Agreement

Service – Rotary’s motto is Service Above Self. Members are willing to participate in undertaking service projects that improve the lives of people in the community and/or around the world. Engagement/Participation – Each member is asked to attend club meetings for fellowship and information, to get involved with club activities, club social events and fund-raising endeavors, to be a member of a committee(s) of their choice, and to participate in local service projects. Financial Support – The Organization is not responsible for paying for the annual membership fee. Members are responsible for meal cost when attending club meeting(s), fundraising tickets, and are encouraged to support The Rotary Foundation that helps Rotarians continue Doing Good in Brick City and the World.

Organization's Primary Designee Signature *

Date of Primary Designee Signature *

Sponsor Signature *

Date of Sponsor Signature *

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