Directory Form

US JCI Senate Directory Update

Red stars indicate required fields.
Senator Name*

First NameLast Name
Senate Number*
State Organization*

Street Address

Street Address Line 2

CityState

Zip Code
Position*
If Position is Other use box below
Other
If position not listed
Birth Month
Birth Date
Date Elected*

MonthDayYear
Date
Date Inducted*

MonthDayYear
Date
E-mail*
Verify E-mail*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary Phone Number*
Format: (000) 000-0000.
Secondary Phone Number
Format: (000) 000-0000.
Spouse/Partner

First NameLast Name
Spouse Senate or Friendship Number
Anniversary Date

MonthDayYear
Date
Who should receive dues billing?*
State Events (INCLUDE DATES) to be listed in the Directory. (Note Directory goes out late July or Aug)
Should be Empty:

US JCI Senate Directory Update