Date*

Rotary Club Name*

Rotary District*

Club Size

Club Website

Contact Name*

Email*

Phone Number

Fax Number

Address*

City*

State*

Postal Code*

Country*

Secondary Contact Name

Secondary Contact Email

Secondary Contact Phone Number

Secondary Contact Fax Number

Secondary Complete Address

Club's special interests in HIV/AIDS projects, if any (such as, ability to supply in-kind medical equipment; special skills of volunteers; established contact with specific country or city through Rotary or other organization; club focus on yout, etc.). One or two sentences please.*

Previous HIV/AIDS projects in this Club, if any. One or two sentences please.