Application for Membership
YES! I am age 21-39 and want to make a difference in my community!
Name
Birthdate
Address
City
State
Zip
Home Phone Number - -
Business Phone Number - -
Email Address
Spouse's Name
Referred by
Social Activities Social Security Reform Business Networking
Environmental Awareness Medicare Reform International Affairs
Personal Development Youth Smoking Issues Community Involvement
Professional Development Social Issues Family & Youth Activities
Governmental Affairs Sporting Activities
Other
In submitting this application, you are not bound to this organization. You will be contacted by a member of the Jaycees about official membership and dues.
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Copyright © 2004 [Pierre Jaycees]. All rights reserved. Revised: February 11, 2004.
