MARYLAND JCI SENATE
MEMBERSHIP APPLICATION
Name
Address
City
State		Zip
JCI Senate Number
Chapter that presented your Senatorship:
Phone:	(H)
	(W)
Would you prefer not to be called at work?
May we leave a message?
E-mail:
May we publish your e-mail address in the directory?
(If not, your e-mail address will be used only for meeting notification and news.
Blind Copy only will be used to send this information.