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Interest in membership in a Rotary Fellowship for Global Development

1.Thank you for your interest in a potential Rotary Fellowship for Global Development. By filling out this form, you are becoming a member of the Fellowship. We may have a small membership fee in the future,  probably $10-$15 per year, as done by several other fellowships to cover administrative costs. But for now, membership is free. Please provide us with basic information to be able to contact you, as well as an indication of the reasons why you are interested in membership and how you would like to contribute. if you have any question, please send an email to Quentin Wodon  at rotarianeconomist@gmail.com. 
2.Title (Mr., Ms., Mrs., Dr., etc.)
3.First name
4.Last name
5.Gender
6.Year of birth - OPTIONAL
Date / Time
7.Are you a Rotarian, Rotaractor, or Peace Fellow? Please indicate all that apply.
8.If you are a Rotarian or Rotaractor, please indicate the name of your club, the number of your district, and your personal Rotary International ID number if you know it
9.In which country are you located?
10.Email
11.Preferred phone number
12.Alternate phone (if applicable)
13.Preferred mailing address (not an email address - a  mailing address) - OPTIONAL
14.Please indicate if the address is residence, business, or other
15.Job title if currently employed
16.Name of business or organization
17.Classification (type of job/profession)
18.Could you tell us briefly how you heard about us?
19.Please tell us about yourself (short bio)
20.Are you interested in one or more activities in particular that would be beneficial to the fellowship? If so, please explain?
21.Any comments on suggestion on priorities for the fellowship? Thank you for completing this brief survey and we will be in touch.