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 | www.jackandjillinc.org | (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.
Chapter
Member’s Last Name
Address
Home Phone
Email Address
1. Name (Last, First)
Name
Name
State Region:FBS
First Name Middle Initial
State
Business Phone Cell Phone
City Zip
2. Name (Last, First)
Phone Number
Phone Number
Member Information
A
Installation Chapter (if different)
State Region
Current Chapter
State Region
Instructions: Please check the appropriate membership box below:
Membership Information
B
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
C
Instructions: Give names and phone numbers of two members who were installed with you or were present during your
installation.
Instructions: List any other chapter in which you have held membership (if not listed above).
Chapter Date of Installation
State
