Printable Membership/Renewal Form

JAC Membership / Renewal Form

(Please print and fill out this form completely and mail with contributions to
JAC, PO Box 105, Highland Park, IL 60035)

Contributor’s Name ______________________________________________________

Address _______________________________________________________________

City ________________________________________ State ______ Zip ___________

Phone _________________________ Business Phone ________________________

E-mail ___________________________________ FAX ________________________

Occupation ____________________________________________________________

Employer ______________________________________________________________

Basic members receive a quarterly newsletter, Joint Action Update, and an invitation to Annual Meeting and community events. In addition to these benefits, Leadership Circle members receive the JAC Newsbreak, a monthly update on issues and races, and invitations to selected events. Hineni Division members receive all of the above plus personal invitations to special events and private briefings.

Membership Levels:
Hineni Division	$5000	___
Diplomat	$2500	___
Congressional Circle	$1000	___
Pacesetter	$500	___
Patron	$250	___
Basic Member	$150	___

I am already a member of JAC.
I would like to make an additional donation in the following amount: ____________.

Personal Check (payable to JAC) Visa MasterCard

Card number ______________________________________ Expiration date ________

Signature _______________________________________________________________

Federal law requires political committees to report the name, mailing address, occupation and employer for each individual whose contributions aggregate in excess of $200 in a calendar year. According to law, JAC cannot accept corporate contributions. Membership, gifts, or other payments to JAC are not deductible as charitable contributions for federal income tax purposes.