JCIセネター資格申請申込書

ＪＣＩセネター資格申請申込書
（公社）日本青年会議所御中
年
ＪＣＩセネターの申し込みをお願い致します。
氏名
自宅住所
月
申請者名
日
印
（英語）
〒
英文住所
電話
（
勤務先住所
〒
電話／ＦＡＸ
ＴＥＬ
）
（
生年月日
）
１９
ＦＡＸ
年
（
月
日
月
日
）
Ｅメール
勤務先
勤務先・役職
役職
英文名
ＪＣ入会
ＪＣ活動歴
ＬＯＭ歴
及び出向歴
現在の役職
年
月
日
卒業
（OB のみ）
西暦
年 LOM･ﾌﾞﾛｯｸ･地区･日本 JC
西暦
西暦
西暦
年 LOM･ﾌﾞﾛｯｸ･地区･日本 JC
年 LOM･ﾌﾞﾛｯｸ･地区･日本 JC
年 LOM･ﾌﾞﾛｯｸ･地区･日本 JC
西暦
年 LOM･ﾌﾞﾛｯｸ･地区･日本 JC
年
ＬＯＭ理事長
の推薦文
理事長署名欄
青年会議所理事長
※理事長本人の申請の場合は直前理事長の推薦文及び署名捺印
Office Use Only :
（備考）
受付年月日
受付番号
入金年月日
処理
印
APPLICATION FOR SENATORSHIP
SUBMIT APPLICATION TO:
Junior Chamber International
ATTN: Senate Administrator
15645 Olive Blvd.
Chesterfield MO 63017, U.S.A.
Tel: (1)(636)449-3100
FAX: (1)(636)449-3107
E-mail: [email protected]
PROCESSING AND SHIPMENT:
Please allow approximately three weeks for processing and mailing
from the JCI Headquarters. Package will be shipped by:
 Regular Mail, unless otherwise indicated. Delivery may take up to
six weeks.
 UPS (courier service), which provides fast and guaranteed
delivery to most regions. Shipping cost:
Area A - US$71.74* Area C - US$44.38*
Area B - US$35.88* Area D - US$35.76*
United States - US$20.00*
* The shipping cost includes shipping for two senatorships. More than two will
be an additional cost.
APPLICANT’S DATA
Please PRINT clearly in BLOCK LETTERS
We wish to file an application for membership in the JCI Senate for:
First Name
Middle Name
Last Name
Address of Applicant
City, State, Zip Code (Postal Zone)
Tel. (Res.):
Country
Tel. (Bus.):
Email Address (IMPORTANT):
Fax:
Date of Birth (e.g. 11/2/58):
Month
Day
Year
Occupation:
JUNIOR CHAMBER HISTORY OF APPLICANT
Date applicant joined Junior Chamber:
Date applicant ceased to be a member (if applicable):
Activities in Junior Chamber
Current and Past Junior Chamber Position(s) of Applicant
Reason(s) for Award of Senatorship
If space is insufficient, please include additional page(s).
LANGUAGE PREFERENCE
Please check () the appropriate box provided below.
Applicant would like to receive certificate in:
English
Spanish
Junior Chamber International (JCI), Inc.  15645 Olive Blvd, Chesterfield, M0 63017, U.S.A.
Tel.: (1) (636) 449-3100  Fax: (1) (636) 449-3107  Homepage: www.jci.cc  Email: [email protected]
French
APPROVAL PROCESS
No approval other than indicated below shall be required or permitted.
Name of Local Organization:
(Please PRINT)
Approved by:
x
(Signature of Chapter President)
(Date)
Name of State Organization:
(Please PRINT)
if applicable
Approved by:
x
(Signature of State President)
(Date)
Name of National Organization:
(Please PRINT)
Approved by:
x
(Signature of National President)
(Date)
Please ensure that all the above  required signatures are obtained as requested
before submitting application to the JCI Headquarters.
INFORMATION FOR SURPRISE PRESENTATION
(Please PRINT information clearly below.)
If Senatorship is to be presented as a surprise, please provide the following information (if this information is not provided,
documents will be sent to the corresponding national organization):
Name :
Address:
IMPORTANT: If courier shipment is required, kindly provide the STREET ADDRESS ↑ (no P.O. box, please)
City, State, Zip Code (Postal Zone)↑
Tel. (Bus.)#:
Fax#:
Country
Tel. (Res.)#:
Email Address:
Date Senate Document Must Be Received:
Formal Presentation Date:
PAYMENT OPTIONS
Please submit US$300 for payment of a lifetime Senatorship.
. Kindly select () from the following payment options:
CREDIT CARD
Check () appropriate box:
NOTE: There is a US$10 credit card processing fee per applicant.
MASTERCARD
DINERS CLUB
VISA
AMERICAN EXPRESS
Clearly PRINT card#:
Clearly PRINT Expiration Date:
x
Signature
Name of Credit Card Holder (please PRINT clearly) ↑
CHECK DRAWN ON
A U.S. BANK
NOTE: Check should be drawn on a U.S. bank in US dollars made payable to Junior
Chamber International (to address indicated at the very bottom of this page).
WIRE TRANSFER
NOTE: Please cover the wire transfer bank fee at your end, OR include an extra US$20 to
cover the wire transfer transaction fee at JCI’s end.
To ensure the proper account is credited, please send a fax (636-449-3107) or email to the attention of the Senate Administrator
at [email protected]) with the following information:
 PLEASE SEND PAYMENT TO:
Enterprise Banking, 300 St. Peters Centre Boulevard
St. Peters, MO 63376, U.S.A.
Account: 0000076291
ABA (routing no.): 081006162 SWIFT CODE: ENTRUS44
Junior Chamber International (JCI), Inc.
1) Amount of transfer
2)
Transaction date
3)
Reason for transfer (e.g. Senatorship).
Junior Chamber International (JCI), Inc.  15645 Olive Blvd, Chesterfield, M0 63017, U.S.A.
Tel.: (1) (636) 449-3100  Fax: (1) (636) 449-3107  Homepage: www.jci.cc  Email: [email protected]
JCI セネター資格取得申込金支払方法連絡
※クレジットまたは電信為替のいずれかに□チェックを頂き、必要事項をご記入下さい。
□クレジットカード / Credit Card
□VISA
□AMEX
□MASTER
□DINERS
①Card Number（口座番号）
：
②Expiration Date（有効期限）
：
③Cardholder Name on Card（カード名義）
：
④連絡先 TEL
：
E-MAIL：
⑤Signature（署名）
：
□電信為替 / Wire Transfer
※送金控えのコピーを必ず添付してご送付ください。
①申請人氏名（日本語）
：
（英語）
：
②連絡先 TEL
：
E-MAIL：
＜送金先口座＞
口座名：Junior Chamber International (JCI),Inc
口座番号：0000076291
ABA(routing no.): 081006162
銀行名：Enterprise Banking
銀行住所：300 St.Peters Centre Boulevard, St.Peters, MO 63376,USA
振込受取人住所：15645 Olive Blvd, Chesterfield,MO63017,USA
振込受取人 TEL：1-636-449-3100

Download Report