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Enclosed is a check for ____ $ 30.00 Annual Dues
____ $300.00 Life Time Dues
Please note any corrections or changes: (Please Print Clearly)
(Annual Dues are due every
June)
NAME ________________________________ SENATE# ___________
ADDRESS ________________________________________________
CITY _________________________ STATE _______ ZIP __________
SPOUSES NAME ____________________ HOME PH _______________
FIRM NAME ________________________ WORK PH ______________
E-mail Address ___________________________________________
Chapter that presented your Senatorship
_______________________
Make check payable to the "California JCI Senate" and
Mail to: Treasurer
Gina Kortz # 67145
4100 The Woods Dr. #414
San Jose, CA 95136
treasurer@cajcisenate.org
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