I would like more information on how to become a member of
COVINGTON-KENTON COUNTY JAYCEES
(Fill out only what informantion you feel comfortable in giving at this time)

 
 
 

Name
Birthdate
Address
City
State		ZIP
Home Phone		Business Phone
Fax #		E-mail
Employer
Title
Spouse's Name
Referred by
I would like to refer
Phone

Dues paid by:

SelfEmployer

Areas of Interest: (check all that apply)
Social Events	Professional Development	Environmental Awareness
Family and Youth Activities	Personal Development	Sporting Activities
Community Involvement	Business Networking	Social Issues
International Affairs	Governmental Affairs

 

Other Interests Not Listed:

Dues are not tax deductible as a charitable contribution

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