Membership Application

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Fill Out This Form For Us:

First Name:
Last Name:
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I am interested in the following:
Social Issues	Environmental Issues	Personal Development
Community Development	Meeting New People	Governmental Affairs
Social Security Reform	Medicare Reform	Professional Development
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International Affairs	Other:

Yes! I am between the ages of 21 and 39 and want to increase my opportunities for success by becoming a member of the U. S. Junior Chamber

Are you aware of the $50 annual membership fee?Yes No

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Send mail to Angela Massey with questions or comments about this web site.