Life Membership Application
This application must be submitted with the Per Capita Tax Report.
See reverse side for further instructions.
1930 17th Street, NW Washington, DC 20009 | | (202) 667-7010
Since 1938
Jack and Jill of America, Incorporated
Instructions: Applicants must complete ALL sections of this form. Members who meet the following criteria may apply for
Life Membership: 1. An active member of Jack and Jill of America, Inc. for at least ten (10) years (this can be as an “Active”
mother in a chapter or combined with the number of years as a financial Associate.); 2. Have completed your tenure in good
standing; and 3. Have reached Associate status.
Member’s Last Name
Home Phone
Email Address
1. Name (Last, First)
State Region:FBS
First Name Middle Initial
Business Phone Cell Phone
City Zip
2. Name (Last, First)
Phone Number
Phone Number
Member Information
Installation Chapter (if different)
State Region
Current Chapter
State Region
Instructions: Please check the appropriate membership box below:
Membership Information
National: 10 year member $450
National: 15 year member $350 National: 20 year member $250
Instructions: List all previous names you have used as a member of Jack and Jill.
Past Information
Instructions: Give names and phone numbers of two members who were installed with you or were present during your
Instructions: List any other chapter in which you have held membership (if not listed above).
Chapter Date of Installation
Life Membership
1930 17th Street, NW Washington, DC 20009 | | (202) 667-7010
Include this document when submitting the chapter's per capita. Submit electronically to:, one (1) copy
to National Headquarters at 1930 17th Street, NW, Washington, DC 20009, one (1) copy to your Regional Treasurer and
Regional Secretary and retain (1) copy for the Chapters’ records.
Instructions: This form must be submitted with the appropriate payment to National in the form of a certified or cashier’s
check, money order or chapter check payable to Jack and Jill of America, Inc. for National Life Membership. Life Members
can be financial on the Local level by paying any dues upon which the Local Chapter and Associates mutually agreed upon.
More information on National Life Membership can be found in the Jack and Jill National Constitution and Bylaws. Chapter
Administrators must update MIS by changing their Membership Category to “Life (National)”. National Headquarters will
complete the application process upon full review. Application and payment must be postmarked by October 1st and must
accompany the Per Capita Tax Report.
Submitting the Application
Applicant’s Signature
Chapter President’s Signature
Chapter Administrator’s Signature
For Ofce Use Only
Date Received in National Ofce
Date Received by Regional Treasurer
Reg Code Chapter Code Member Number
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