Fillable Jack and Jill of America, Incorporated

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Jack and Jill of America, Incorporated

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Associate/Terminated Reactivation Form
1930 17th Street, NW Washington, DC 20009 | www.jackandjillinc.org | (202) 667-7010
Since 1938
Jack and Jill of America, Incorporated
Chapter
State Region
Instructions: Use this form to reactivate Associates who are not listed in MIS and Terminated Members who have submitted per capita fees
after September 30. The member’s profile will be updated upon receipt of the per capita payment.
This form is not required for Associates applying for Life Membership or Associates listed as Non-Participating in MIS. Associates
applying for Life Membership must complete the Life Membership Application. Associates listed as Non-Participating in MIS can be reactivated
using the Associate Non-Participating to Associate Participating wizard.
Program Year
1
Member’s Last Name
Address
Home Phone
First Name Middle Initial
State
Email
City Zip
2
Member’s Last Name
Address
Home Phone
First Name Middle Initial
State
Email
City Zip
3
Member’s Last Name
Address
Home Phone
First Name Middle Initial
State
Email
City Zip
4
Member’s Last Name
Address
Home Phone
First Name Middle Initial
State
Email
City Zip
Associate/Terminated
Reactivation Form
1930 17th Street, NW Washington, DC 20009 | www.jackandjillinc.org | (202) 667-7010
Include this document when submitting the Per Capita Fee. Submit electronically to: finance@jack-and-jill.org, one (1) copy to
National Headquarters at 1930 17th Street, NW, Washington, DC 20009, one (1) copy to your Regional Treasurer and retain (1)
copy for the Chapters’ records.
5
Member’s Last Name
Address
Home Phone
First Name Middle Initial
State
Email
City Zip
6
Member’s Last Name
Address
Home Phone
First Name Middle Initial
State
Email
City Zip
7
Member’s Last Name
Address
Home Phone
First Name Middle Initial
State
Email
City Zip
8
Member’s Last Name
Address
Home Phone
First Name Middle Initial
State
Email
City Zip
9
Member’s Last Name
Address
Home Phone
First Name Middle Initial
State
Email
City Zip
10
Member’s Last Name
Address
Home Phone
First Name Middle Initial
State
Email
City Zip
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Jack and Jill of America, Incorporated

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Completed 10 November 2021

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