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* 1. Thank you for your interest in a potential Rotary Fellowship for Global Development. In order to apply to Rotary International for the creation of the fellowship, we need at least 25 potential members from 5 countries. Membership is open to non-Rotarians as well as Rotarians. The fellowship would provide opportunities for learning and networking for its members, and would maintain a website with resources on international development beneficial to Rotarians. By filling out this form, you are expressing your interest in becoming a member of the fellowship. Membership would entail a small fee,  probably $10-$15 per year, as done by several other fellowships to cover administrative costs. 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 to the fellowship if it is approved. if you have any question, please send an email to Quentin Wodon  at rotarianeconomist@gmail.com. Please type your initials below to acknowledge that membership in the fellowship if it is approved would entail a small annual membership fee as indicated above.

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* 2. Title (Mr., Ms., Mrs., Dr., etc.)

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* 3. First name

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* 4. Last name

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* 5. Gender

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* 6. Year of birth - OPTIONAL

Date

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* 7. Are you a Rotarian, Rotaractor, or Peace Fellow? Please indicate all that apply.

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* 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

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* 9. In which country are you located?

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* 10. Email

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* 11. Preferred phone number

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* 12. Alternate phone (if applicable)

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* 13. Preferred mailing address (not an email address - a  mailing address) - OPTIONAL

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* 14. Please indicate if the address is residence, business, or other

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* 15. Job title if currently employed

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* 16. Name of business or organization

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* 17. Classification (type of job/profession)

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* 18. Could you tell us briefly how you heard about us?

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* 19. Please tell us about yourself (short bio)

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* 20. Are you interested in one or more activities in particular that would be beneficial to the fellowship? If so, please explain?

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* 21. Any comments on suggestion on priorities for the fellowship? Thank you for completing this brief survey and we will be in touch.

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