Please take a moment to provide the following information.

Пожалуйста, заполните данную регистрационную форму

 ITHF Registration Form

Регистрационная форма ITHF

You are purchasing a: 3 Year Membership $75.00

Оплачивая $75.00, Вы становитесь членом ITHF на 3 года

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Last or family name:

Фамилия:

 

First name (preferred) / Имя (как Вы предпочитаете)

Spouse's name:

Имя супруги(а)

  Check if spouse is Rtn **

Отметьте, если супруг(а) член РИ

Name as desired on mailing lables:

Desired USERNAME:

Имя пользователя (по Вашему желанию)

PASSWORD:

ПАРОЛЬ:

Re-enter Password:

Введите ПАРОЛЬ повторно:

Residential Address:

Адрес места жительства:

Address (full and complete) Line 1:

Адрес (полный и подробный) Строка 1:

Line 2:

Строка 2:

City:

Город:

Postal Code:

Почтовый индекс:

County:
(If applicable)

Округ

(если применимо)

Country:

Страна: (выбрать)

Select a Country or Location World Afghanistan Akrotiri Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Arctic Ocean Argentina Armenia Aruba Ashmore and Cartier Islands Atlantic Ocean Australia Austria Azerbaijan Bahamas Bahrain Baker Island Bangladesh Barbados Bassas da India Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Clipperton Island Cocos (Keeling) Islands Colombia Comoros Congo, Democratic Republic of the Congo, Republic of the Cook Islands Coral Sea Islands Costa Rica Cote d' Ivoire Croatia Cuba Cyprus Czech Republic Denmark Dhekelia Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Europa Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern and Antarctic Lands Gabon Gambia, The Gaza Strip Georgia Germany Ghana Gibraltar Glorioso Islands Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard and McDonald Islands Holy See (Vatican See) Honduras Hong Kong Howland Island Hungary Iceland Iles Eparses India Indian Ocean Indonesia Iran Iraq Ireland Israel Italy Jamaica Jan Mayen Japan Jarvis Island Jersey Johnson Atoll Jordan Juan de Nova Island Kazakhstan Kenya Kingman Reef Kiribati Korea, North Korea, South Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Man Isle of Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Ethiopia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Namibia Nauru Navassa Island Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pacific Ocean Pakistan Palau Palmyra Atoll Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Spratly Islands Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tromelin Island Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Pacific Island Wildlife Refuges Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands (US) Wallis and Furuna Islands Western Sahara Western Samoa Yemen Yugoslavia Zaire Zambia Zimbabwe Taiwan European Union

State, Province or Region:

Край, область или регион:

Mailing Address: (if different)

Почтовый адрес: (если отличен от адреса проживания)

Address (full and complete) Line 1:

Адрес (полный и подробный) Строка 1:

Line 2:

Строка 2:

City:

Город:

Postal Code:

Почтовый индекс

County:
(If applicable)

Округ

(если применимо)

State, region or province:

Край, область или регион:

Country:

Страна: (выбрать)

Select a Country or Location World Afghanistan Akrotiri Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Arctic Ocean Argentina Armenia Aruba Ashmore and Cartier Islands Atlantic Ocean Australia Austria Azerbaijan Bahamas, The Bahrain Baker Island Bangladesh Barbados Bassas da India Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Clipperton Island Cocos (Keeling) Islands Colombia Comoros Congo, Democratic Republic of the Congo, Republic of the Cook Islands Coral Sea Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Dhekelia Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Europa Island Falkland Islands (Islas Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern and Antarctic Lands Gabon Gambia, The Gaza Strip Georgia Germany Ghana Gibraltar Glorioso Islands Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See (Vatican City) Honduras Hong Kong Howland Island Hungary Iceland Iles Eparses India Indian Ocean Indonesia Iran Iraq Ireland Israel Italy Jamaica Jan Mayen Japan Jarvis Island Jersey Johnston Atoll Jordan Juan de Nova Island Kazakhstan Kenya Kingman Reef Kiribati Korea, North Korea, South Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Man, Isle of Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Midway Islands Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Namibia Nauru Navassa Island Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pacific Ocean Pakistan Palau Palmyra Atoll Panama Papua New Guinea Paracel Islands Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Southern Ocean Spain Spratly Islands Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tromelin Island Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Pacific Island Wildlife Refuges Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands (US) Wake Island Wallis and Futuna West Bank Western Sahara Yemen Zambia Zimbabwe Taiwan European Union

Local Attractions:

Residence Telephone:
(include all prefixes)

Домашний телефон

(со всеми кодами)

Cell phone:
(include all prefixes)

Мобильный телефон

(со всеми кодами)

Fax:

Факс

email:

электронный адрес:

secondary email (optional):

второй электронный адрес (не обязательно):

Your homepage:

Ваша домашняя страница

Rotary Club:

Ротари клуб:

District:

Округ:

Classification:

Классификация:

Years in Rotary:

Сколько лет в Ротари:

Key Positions Held:

Основные позиции, которые занимали:

Nearest City or Large Town:

Ближайший большой город или районный центр:

Special Rotary Interests:

Особые интересы в Ротари:

Other Interests:

Другие интересы:

** Spouse Info.:

Информация о супруге:

Languages you speak:

Вы говорите на языках:

Your Skype name:
(ONLY if applicable)

Позывные в Skype:

(ТОЛЬКО если применимо)

I do not need a printed newsletter mailed to me.

Мне не нужно присылать печатный информационный бюллетень по почте.

Method of Payment:

Способ оплаты:

Check (paper mail)

Чек (обычная почта)

  Credit Card (electronic)

Кредитная карта (электронная)

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