Save and/or print out the following form.

Send the completed form as an email attachment to jaycees@glen-ellyn.com 
or by fax 630-790-9552

Thank you... and welcome!

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

GLEN ELLYN JAYCEES MEMBERSHIP APPLICATION:

_X_Yes! I want to become one of America's young leaders in action!

Name: 
Address: 
City, State ZIP: Glen Ellyn, IL 60137

Birthdate: 

Home Phone: 
Work Phone: 
Fax Phone:	
E-mail Address:
Employer: 	
Social Security or Driver's License Number
(kept confidential): 
Spouse's Name: 
Referred By: Bill Nicholson			
I would like to refer:		
Their phone:			

MY AREAS OF INTEREST ARE:

Social Activities__
Environmental Awareness__
Personal Development__
Community Involvement__
Social Issues__
Governmental Affairs__
Social Security Reform__
Medicare Reform__
Youth Smoking Issues__
Professional Development__
Family & Youth Activities__
Sporting Activities__
Business Networking__
International Affairs__
Other: __________________________________

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -