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JCI Rochester Application
Welcome to the Rochester Jaycees! Please fill out this form so we can learn more about you and your goals!
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Email
*
Your email
First Name
*
Your answer
Last Name
*
Your answer
Gender/Pronouns
*
Male (he/him/his)
Female (she/her/hers)
Non-Binary or Agender (they/their/theirs)
Other:
Birthdate
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MM
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DD
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YYYY
Street Address (including Apt)
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Your answer
City
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Your answer
State
*
Your answer
Zip Code
*
Your answer
Phone Number
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Your answer
Is the Phone Number provided Cell, Home, or Work?
*
Cell
Home
Work
How would you define an "Active Citizen"?
Your answer
What are you hoping to accomplish by joining this organization?
Your answer
What are your long term professional goals?
Your answer
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