Thank you for your interest in the Rockford Jaycees! The following information will help us to get to know you better and keep in touch with you. Only list you work phone if you are comfortable accepting calls there. PLEASE PRINT ALL INFORMATION!

Name: ____________________________

Date of Birth: _______________________

Address: ___________________________

City, Zip: ___________________________

Home Phone: _______________________

Work or Cell Phone: __________________

Are you: Single Married (check one)

Spouse's Name: _________________

Would you like to receive updates on Jaycees events via e-mail?

Yes No

If yes, please PRINT your e-mail address: ____________________________________

Do you have any children? What are their names and ages?

How or from whom did you hear about the Rockford Jaycees?

How long have you lived in the Rockford area?

Where do you work and what is your position?

What are your hobbies and interests?

____________________________________________________

Yes, I want to join the Rockford Jaycees!

____________________________ ____________

Signature Date

______________________________

Printed Name

Membership Dues - $60 per year

Makes Checks to - Rockford Jaycees

Application can be mailed to: P.O. Box 585 Rockford, MI 49341