Charter Membership Application & Payment Information

This form collects the personal, club, and payment details needed to process a charter membership application for a public-speaking club.

Use this template

Applicant Type

Do you use assistive technology (such as a screen reader) to view your educational materials?

Yes No

Preferred Accessible Format (if applicable)

Additional Accessibility Notes

Membership Type

New Member Reinstating Member Transferring Member Dual Member

Club Number

Club Name

Club City

Club Country

United States Canada Other

Gender - Other (please specify)

Do you identify as non-binary?

Yes No

Would you prefer not to specify your gender?

Yes No

Full Name

Nombre

Apellido

First Name

Last Name

Date of Transfer (MM/YYYY)

Organization/In Care Of

Previous Club Number

Address Line 1 (limit 35 characters)

Member Number

Address Line 2 (limit 35 characters)

City

State or Province

Country

Postal Code

Home Phone Number

Mobile Phone Number

Email Address

Toastmasters International Dues and Fees

I understand the dues and fees structure below

New Member Fee (one-time)

New Member Fee Amount (US$)

Monthly Dues Amount (US$)

International Per-Capita Dues

International Dues Amount (US$)

Club Dues

Total Amount Due

International Fees and Dues US$ (from line 4 above) Club new member fee

US$45.00

Membership Start Month: November

November

Prorated Dues Amount for November (US$)

Membership Start Month: December

December

Prorated Dues Amount for December (US$)

Membership Start Month: January

January

Prorated Dues Amount for January (US$)

Membership Start Month: February

February

Prorated Dues Amount for February (US$)

I want my membership to begin

Membership Start Month: March

March

Prorated Dues Amount for March (US$)

Additional Notes on Membership Start

For this purpose, please check the box below corresponding to acceptable contact methods

Email Phone Mail Text Message

For this purpose, please check the box below corresponding to acceptable contact methods

Email Phone Mail Text Message

Additional Contact Information

Applicant Certification Statement

Applicant's Signature

Sign here

Date (MM/DD/YYYY)

Club Officer Certification Statement

Club Officer Title

Club Officer's Signature

Sign here

Date (MM/DD/YYYY)

Club Officer Email

Club Officer Phone Number

Payment Section Notice

This section is completed by the applicant and is for payment to World Headquarters only — the amount listed in line 4 on page 1. World Headquarters does not collect club dues.

Check or Money Order Credit Card

This section is completed by the applicant and is for payment to World Headquarters only — the amount listed in line 4 on page 1. World Headquarters does not collect club dues.

I authorize this payment

Payment Amount (US$)

Amount Enclosed (US$)

Check or Money Order Number

Paying by Check or Money Order

Card Number

Expiration Date

Other

Name on Card

Signature

Sign here

I acknowledge that my electronic signature on this document is legally equivalent to my handwritten signature.

I agree

Address Line 1

Address Line 2

City, State or Province

Country, Postal Code

Charter Membership Application & Payment Information

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