Senator's Name:

Senate Number: #

Former Name (if name change):

Senator's Email:

Spouse's Name:

Address:

City:

State:

Zip:

Home Phone:

I would like to give back to the Missouri Jaycees by (list all):

¨ Training at Local Officers Training Session:
¨ Training at Local, Region or State Meeting:
¨ Speaking at Local, Region or State Meeting:
¨ Assisting on a Chapter Recruitment Drive (supplying name, knock & talk, etc.)
¨ Assisting with a new Chapter Affiliation (extension)
¨ Serving as Senate Project Chair Person
¨ Donating prizes for raffles or silent auctions