JUNIOR STATE OF AMERICA TAX FORM

SCHOOL NAME: ____________________________ DATE:_________________________

To start a JSA chapter at your school you will need the following:
* a minimum of 8 tax-paid student members listed on this form
* a Teacher-Advisor from your school
* school approval
* a chapter constitution (see example in handbook)
"Taxes" are the dues paid to join a chapter; $3.00 per member, per year. After the initial eight students
have joined, you may send in any number of additional members throughout the year, by mailing the
taxes and completed tax form to:

For the West Coast and Texas For the East Coast and Midwest
THE JUNIOR STATE OF AMERICA THE JUNIOR STATE OF AMERICA
400 S. EL CAMINO REAL, SUITE 300 1725 K St NW, Suite 1214
SAN MATEO, CA 94402 WASHINGTON, D.C. 20006

CHAPTER PRESIDENT TEACHER/ADVISOR

____________________________________ ___________________________________________
NAME NAME
_________________________________________________ __________________________________________________________
HOME ADDRESS SCHOOL ADDRESS
_________________________________________________ __________________________________________________________
CITY STATE ZIP CITY STATE ZIP
(________)________________________ ______________ (________)________________________________________________
HOME PHONE NUMBER GRADUATION YEAR SCHOOL PHONE NUMBER
__________________________________________________ _________________________________________________________
E-MAIL ADDRESS E-MAIL ADDRESS

(________)_________________________________________ (________)________________________________________________
CELL PHONE NUMBER CELL PHONE NUMBER

TAX-PAID STUDENT MEMBERS (Chapter President's information goes first):

1. __________________________________________________________________________________________________
Name Address City State Zip

_________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

2. __________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

3. __________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

4. _________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

5. __________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number
TAX-PAID STUDENT MEMBERS FOR SCHOOL_______________________________________

6. __________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

7. __________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

8. _________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

9. __________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

10._________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

11._________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

12._________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

13.________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

14._________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

15._________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

16._________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

17._________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

18._________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

19._________________________________________________________________________________________________
Name Address City State Zip

_________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

20.________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

USE ADDITIONAL COPIES AS NECESSARY - PLEASE FILL OUT COMPLETE ADDRESSES AND PHONE NUMBERS!
TAX-PAID STUDENT MEMBERS FOR SCHOOL_______________________________________

21._________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

22._________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

23._________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

24._________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

25._________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

26._________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

27._________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

28._________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

29._________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

30._________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

31._________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

32._________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

33._________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

34._________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

35._________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

USE ADDITIONAL COPIES AS NECESSARY - PLEASE FILL OUT COMPLETE ADDRESSES AND PHONE NUMBERS!
TAX-PAID STUDENT MEMBERS FOR SCHOOL_______________________________________

36._________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

37._________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

38._________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

39._________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

40._________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

41._________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

42._________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

43._________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

44._________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

45._________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

46._________________________________________________________________________________________________
Name Address City State Zip

_________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

47._________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

48.________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

49._________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

50._________________________________________________________________________________________________
Name Address City State Zip

__________________________________________________________________________________________________
Year of Graduation Email Address Phone Number

USE ADDITIONAL COPIES AS NECESSARY - PLEASE FILL OUT COMPLETE ADDRESSES AND PHONE NUMBERS!