Please print clearly:
Name: ____________________________________________________________________________________
Were you ever a Junior Optimist International Member? Yes No
Are you currently a full-time college student? Yes No
Are you under 30? Yes No
HOME ADDRESS
Street: ____________________________________________________________________________________
City: ___________________________________ State: ____________________ ZIP Code: ______________
Home Phone: ____________________________ E-mail: ___________________________________________
BUSINESS ADDRESS
Firm Name: ________________________________________________________________________________
Type of Business: __________________________________________________________________________
Street: ____________________________________________________________________________________
City: _____________________________________State: ___________________ZIP Code: ______________
Business Phone: __________________________ Email: __________________________________________
Cell Phone _________________________ Business Position or Title: _______________________________
May we contact you at work? Yes No
YOUR SIGNATURE INDICATES YOUR ACCEPTANCE OF THIS INVITATION:
Signature: __________________________________________ Date: _________________________________
Please include your check for AMOUNT made out to: Optimist Club of NAME
Charter Member Invitaon
AREA NAME Opmist Club
CITY, STATE
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