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Enclosed is a check for ____ $ 30.00 Annual Dues
____ $300.00 Life Time Dues
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Please note any corrections or changes: (Please Print Clearly)
(Annual Dues are due every June)
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NAME ________________________________________ SENATE# ___________
ADDRESS _________________________________________________________
CITY ________________________________ STATE _______ ZIP ____________
SPOUSES NAME ________________________ HOME PH __________________
FIRM NAME ____________________________ WORK PH __________________
E-mail Address _____________________________________________________
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Chapter that presented your
Senatorship _________________________________________
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Make check payable to the "California JCI Senate" and............................
Mail to: Treasurer
Gina Kortz # 67145
325 Union Ave, Apt 248
Campbell, CA 95008
treasurer@cajcisenate.org
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Dues Renewal Form
