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Missouri-Arkansas District

Chartered in 1918

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- New Member Application
Youth Kamp

Kids Need Kiwanis

Kiwanis Club of Benton

Membership Application

Membership Type(Required)

New Kiwanis member

Transferring Kiwanis member

Former Kiwanis member

Corporate Kiwanis member

Current Kiwanis member

Former Service Leadership member

Contact Information

Prefix(Required)

Mr.

Mrs.

Ms.

Dr.

Rev.

Other

Full legal name(Required)

First Middle Last

Preferred Name

Name of Former Kiwanis Club(Required)

Name of Current Kiwanis Club(Required)

Spouse / Partner Name

Name of Company / Business(Required)

Billing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Phone(Required)

Phone Type(Required)

Mobile

Home

Office

Date of Birth

MM slash DD slash YYYY

Dues Information

Annual Membership ($80.00)(Required)

Member Dues

Annual Membership ($25.00)(Required)

Former K-Kids

Former Builders Club

Former Circle K

Former Key Club

Name of Former SLP Club(Required)

Former legal name (returning member whose name has changed)

Total

Payment Information

Payment Type(Required)

Cash

Check / Money Order

Credit / Debit Card

Invoice (Corporate Membership Only)

Check / Money Order Number(Required)

Credit Card

Card Details

Cardholder Name

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