c

c
cccc c c West Ranch Junior State of America

2010/2011 Membership Form

c
The national Junior State of America office requires our chapter to collect
membership dues from each of our members. These dues help maintain the
organization and all of the wonderful events and functions it has been putting
on for the last 75 years. All members are required to pay O
 in
membership dues, in order to be an official member of this prestigious
organization on our campus. Please fill out the membership form bellow no
later then 

O . Please make all checks payable to  



 
.

0
 

Name:________________________________________________________

Home Phone: (____)_____________________

Mobile Phone:(___)_____________

Email address: _________________________________________________

Male: _____ Female: _____ Grade: _____ Cash: _______ Check: ________

Interested in attending the JSA conventions:______________________

Student Signature: ______________________________________________

Parent/Guardian Signature: _______________________________________