Membership Application &

Payment Information
To become a club member, please
1. Completely fill out and sign the Membership Application.
2. Completely fill out and sign the Payment Information document (page 3).
3. Submit both completed and signed documents to a club officer.
4. Please check here ✔ if you use assistive technology (such as a screen reader) to view your educational materials.

For questions, please contact membership@toastmasters.org.

Membership Application
Club Information
This section is completed by a club officer.
_______________________________________________________________________________________________________________________________________
Club number Club name Club city

Applicant Information Membership Type

This section is completed by a club officer.
This section is completed by the applicant. Male Female Non-binary Decline to respond
New Reinstated (break in
Kumar Mudit
_________________________________________________________________________________________ Dual membership)
Last name/Surname First name Middle name R enewing (no break
T ransfer (If applicant
is transferring from in membership)
another club, please
The monthly Toastmaster magazine will be sent to the following address:
fill in the four lines
_________________________________________________________________________________________ below.)
Organization/In care of
_______________________________________
Date of transfer (MM/YYYY)
H.No-158, Station mill road, Seohara
_________________________________________________________________________________________
Address line 1 (limit 35 characters) _______________________________________
Previous club name
_________________________________________________________________________________________
Address line 2 (limit 35 characters) _______________________________________
Previous club number
Bijnor Uttar Pradesh
_________________________________________________________________________________________
City State or province _______________________________________
Member number
India 246746
_________________________________________________________________________________________
Country Postal code

9873110341 tomar.mudit@gmail.com
_______________________________________________________________________________________________________________________________________
Home phone number Mobile phone number Email address

Toastmasters International Dues and Fees
This section is completed by the applicant with the help of a club officer. Dues and fees are payable in advance and are not refundable or transfer-
able from one member to another.

1. New member fee (US$20) 20

US$_________ 3. Total payment to Toastmasters International US$ ________
20
Paid only by new members, this fee covers the cost of the Total of 1 and 2.
first education path, online copy of The Navigator, and processing

2. Membership dues US$_________

Paid twice a year by all members, membership dues are Club Dues and Fees Worksheet
pro-rated from the member’s start month: Club dues must be paid directly to the club. World Headquarters
Date my membership began:__________________________________________ cannot process payments for club dues.
Month/Year International Fees and Dues $ ______________
DISTRICTED (from line 3 above)
 October or   April US$45.00 $_________ Club new member fee ______________
 November or   May 37.50 _________
 December or   June 30.00 _________ Club dues ______________
 January or   July 22.50 _________
 February or   August 15.00 _________ Total payment to club ______________
 March or   September 7.50 _________

Page 1
Sponsor of New, Reinstated, or Dual Member
Transfer and renewing members are not eligible to be sponsored. This section is completed by a club officer.

��������������������������������������������������������������������������������������������������������������������������������������
Sponsor’s last name/surname Sponsor’s first name Sponsor’s member number Sponsor’s club number

Member’s Agreement and Release
Consistent with my desire to take personal responsibility for my conduct, individually and as a member of a Toastmasters club, I agree to abide by the principles
contained in A Toastmaster’s Promise, the Toastmasters International Governing Documents, and my club. I will refrain from any form of discrimination, harassment,
bullying, derogatory, illegal, or unethical conduct, and I understand that if I engage in such conduct, I agree to reimburse Toastmasters International, my club or
other clubs, or other individuals involved with Toastmasters, for any damages, losses, or costs resulting from my conduct. Understanding that Toastmasters programs
are conducted by volunteers who cannot be effectively screened or supervised by Toastmasters International or its clubs, I release and discharge Toastmasters
International, its clubs, governing bodies, officers, employees, agents, and representatives from any liability for the intentional or negligent acts or omissions of any
member or officer of my club or other clubs, or any officer of Toastmasters International. Should a dispute of some nature arise, I expressly agree to resolve all disputes,
claims, and charges relating to Toastmasters, Districts, clubs, and Toastmasters members in accordance with Protocol 3.0: Ethics and Conduct.
By submitting this application, I expressly agree to the following:
■ The collection, use, and processing of the personal information I provide to Toastmasters in this Membership Application for the purposes of organization
administration, payment of my dues, and inclusion of my contact information in a members’ directory that will be distributed to members and employees of
Toastmasters. In addition, the collection, use, and processing of my personal information collected by Toastmasters International through Toastmasters’ website and
by electronic communications.
■ That my information may be accessed and used by Toastmasters, its employees and agents, District leaders, and club officers.
■ Maintain changes to my personal contact information to ensure it is accurate and current by updating my personal profile page located on the Toastmasters
International website: www.toastmasters.org\login. I understand that the majority of the data requested in this application is necessary for administrative and
planning purposes.

Occasionally we would like to contact you with details of services, educational updates, and organizational updates. If you consent to us contacting you for this
purpose, please check the box below corresponding to acceptable contact methods: Mail Email Phone
If you would rather not receive non-essential communications from us, please check here
For our full privacy policy, you may visit www.toastmasters.org/footer/privacy-policy.

Verification of Applicant
A Toastmaster’s Promise
By my signature below, I agree to the terms of A Toastmaster’s Promise and the
As a member of Toastmasters International and my club, I promise Member’s Agreement and Release stated above, and certify that I am 18 years of
 To attend club meetings regularly age or older (in compliance with the Toastmasters Club Constitution for Clubs of
Toastmasters International).
 To prepare all of my projects to the best of my ability, basing
I acknowledge that my electronic signature on this document is legally equiva-
them on the Toastmasters education program lent to my handwritten signature.
 To prepare for and fulfill meeting assignments

 To provide fellow members with helpful, constructive

Mudit Kumar 10-06-2020
Digitally signed by Mudit Kumar
����������������������������������������������������������������
Date: 2020.06.10 21:17:14 +05'30'

Applicant’s signature Date (MM/DD/YYYY)

evaluations
 To help the club maintain the positive, friendly environment
necessary for all members to learn and grow
Verification of Club Officer
 To serve my club as an officer when called upon to do so
I confirm that a complete Membership Application, including the signatures of
 To treat my fellow club members and our guests with respect the new member and a club officer, is on file with the club and will be retained
and courtesy by the club.
By my signature below, I certify that this individual has joined the Toastmasters
 To bring guests to club meetings so they can see the benefits
club identified. As a club, we will ensure that this member receives proper
Toastmasters membership offers
orientation and mentoring.
 To adhere to the guidelines and rules for all Toastmasters I acknowledge that my electronic signature on this document is legally
education and recognition programs equivalent to my handwritten signature.
 To act within Toastmasters’ core values of integrity, respect,
service, and excellence during the conduct of all Toastmasters ����������������������������������������������������������������
activities Club officer’s signature Date (MM/DD/YYYY)

In order for this application to be valid, both signatures are required.

Page 2
The club officer must follow the instructions below once the Membership Application and Payment Information documents are received.
1. Sign and date the applicant’s Membership Application.
2. Submit the Membership Application and Payment Information documents online by logging in to www.toastmasters.org/clubcentral.
You can also mail the documents to Club and Member Support, Toastmasters International, 9127 S. Jamaica St., Suite 400, Englewood, CO 80112,
U.S.A., or fax to +1 303-799-7753. Please use only one of these methods to avoid duplication. If the member is transferring, the application must
be submitted to World Headquarters by email, mail, or fax.
3. After receiving confirmation that Toastmasters International has received and processed the Membership Application and Payment
Information, the club officer must:
a. Retain the applicant’s Membership Application with other club documentation. While held, the application should be kept secure, such as
in a lock box, or destroyed once it is digitally retained. It is up to your club and your country’s privacy guidelines on how long the application
should be retained.
b. Immediately destroy the applicant’s Payment Information document (page 3) and any copies in the club officer’s or club’s possession,
including all electronic copies.

Payment Information
Payment Method to Toastmasters International
This section is completed by the applicant and is for payment to World Headquarters only (the amount listed in line 3 on page 1). World Headquarters
does not collect club dues.

MasterCard Check or money order

Check or money order must be for U.S. funds drawn on a U.S. bank.
Visa

AMEX US$____________________________________________________
Amount
Discover
______________________________________________________
US$____________________________________________________________ Check or money order number
Amount

______________________________________________________________
Card number
Other
______________________________________________________________
Expiration date
______________________________________________________
Other
______________________________________________________________
Name on card

______________________________________________________________
Signature

Check box for Billing Address is the same as Shipping Address

______________________________________________________________________________________________________________________________________
Address line 1

______________________________________________________________________________________________________________________________________
Address line 2

______________________________________________________________________________________________________________________________________
City State or province

______________________________________________________________________________________________________________________________________
Country Postal code

Item 800   Rev. 02/2020 Page 3