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Jaycee Sign-up Form

Please fill out all fields on the form below for our information. However, in order to become an active member, your payment of $85 must be received. Checks made payable to the Santa Monica Jaycees or you may click the icon below to enter PayPal, our secure credit card payment system.

For more information about PayPal and their data security click here.

First Name:
Last Name:

Your Birthdate?
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Your Company?

Home Phone:

Business Phone:

Fax:

Address:
Apt:
City: State: ZIP:

Your Email?

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