Roanoke Jaycees Membership Application

Name           __________________________________________

Address        __________________________________________

                    __________________________________________

                    __________________________________________

Home phone  (______) __________________________________

Work phone   (______) __________________________________

Email            __________________________________________

Employer       __________________________________________

Date of Birth   __________________________________________

How did you find out about the Roanoke Jaycees?

______________________________________________________
______________________________________________________


Payment method

___  Check for $65 payable to "Roanoke Jaycees" is enclosed

___  Please contact me about billing my employer

 

Please bring this application and payment to the next membership meeting or mail to:

Roanoke Jaycees
P. O. Box 1225
Roanoke, VA 24006