Membership Application First Name * Last Name * Date of Birth * Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 12345678910111213141516171819202122232425262728293031 Street Address * City/State/Zip * Preferred Telephone # * Email What do you hope to obtain by your membership in the Jaycees? * What special skills do you have? How did you hear about the Jaycees? Who referred you to the Jaycees? What is your primary profession? * Are you aware of the $60 1st year membership fee? * Yes No