To The Secretary Rotary Club of:

Albury Albury Hume Albury North Albury West Alexandra Appin Park Beechworth Bellbridge Lake Hume Belvoir Wodonga Benalla Bright Broadmeadows Bundoora Cobram Coburg Corowa Corryong Craigieburn Deniliquin Diamond Creek East Shepparton Eltham Euroa Finley Greensborough Heidelberg Rosanna Holbrook Ivanhoe Kyabram Lavington Mansfield Milawa Oxley Mooroopna Moreland Mount Beauty Myrtleford Nathalia Numurkah Pascoe Vale Preston Reservoir Riddells Creek Romsey Lancefield Rutherglen Seymour Shepparton Shepparton Central Shepparton South Southern Mitchell Strathmore Sunbury Tallangatta Tatura Tocumwal Wangaratta Whittlesea Wodonga Wodonga West Yarrawonga Mulwala Yea Select the club

Your Last Name

Your First Name:

Street Address

Suburb

Postcode:

Your Telephone Number:

Date of Birth

Age Last Birthday

School

Current year level

Subjects Studied - Please list:

My Future Ambitions are:

My Other interests are:

Country of First Choice

Why this country?

Second Choice

Third Choice

Why do I want to go overseas?

Date of Application

Your E-Mail Address

Please note: - If you email this form it will go to District 9790 Australia -
Other students should print this form and submit it to their nearest Rotary Club