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:

 

 

Areas of Interest: (check all that apply)

SocialEvents

ProfessionalDevelopment

EnvironmentalAwareness

Familyand Youth Activities

PersonalDevelopment

SportingActivities

CommunityInvolvement

BusinessNetworking

SocialIssues

InternationalAffairs

GovernmentalAffairs

 


 

Other Interests Not Listed:

Dues are not tax deductible as acharitable contribution