Greater Bluefield Junior Chamber
Member Survey

 
Member's Name
Member's Birth Date (MM/DD/YYYY)
Spouse's Name
Spouse's Birth Date (MM/DD/YYYY)
Phone Number
Would you consider asking your spouse to belong?
Yes
No
Would child care be important to have at meetings?
Yes
No
Please list children's names and birth dates
Member's Occupation/Title
Do you own/manage your own business?
Yes
No
Employer/Supervisor's Name
Work Address
Work Phone
Ok to accept calls at work?
Yes
No
Education Level (Choose Highest Completed)
 
Income Level (The US Jaycees Use This For Demographic Reasons)
 
Current affiliations with other organizations
Past personal achievements/awards you have received
Past leadership experience
Church and other hobbies
Hobbies
Date joined Junior Chamber
Sponsored/referred by

How did you find out about the organization?
Do you desire to serve in a leadership position?
Yes
No
If yes, any particular area?
Areas of interest
Do you feel the day, time, and place of chapter meetings is satisfactory?
Yes
No
If no, what would you suggest (When and Where)?
What programs/projects are needed to conduct in our community?
What projects interest you the most?
 
Jaycees Against Youth Smoking      
Junior Chamber Mission Inn         
Shooting Education                 
Ten Outstanding Young Americans  
National Outstanding Young Farmer  
Entrepreneurs Program              
Value Investing                   
Career Advancement               
Other                              
Is there a project that we conduct now that you feel should be dropped (name)?
Is there a project that we don't conduct now that you would like to see us start? (Name)
How can we better service the community?
How can we better serve you?
Who are three (3) people you would recommend to join the organization?
 
First Name
Last Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
E-mail
Accept calls at work?
Yes
No
First Name
Last Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
E-mail
Accept calls at work?
Yes
No
First Name
Last Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
E-mail
Accept calls at work?
Yes
No

 

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