FORM #3A

Junior Chamber International Philippines

Developing Leaders for A Changing World
14 Don A. Roces Avenue, Brgy. Paligsahan, 1103 Quezon City
Telephone No. (02) 8373-4138
E-mail: NOM@philjaycees.com Website: www.jciphilippines.com

2022 LOCAL MEMBERSHIP DECLARATION

Date: _______________________

Name of Local Organization____________________________ Region:____________ Area:_____________

LOM Address________________________________________________________________________________

Attention: The National Treasurer/The National Secretary-General, JCI Philippines

We, ________________________________, LO President and __________________________________,

LOM Secretary of ____________________________ for the year 2022 hereby declared that our LO has the
following membership for the year 2022:

___________________________ ____________________________________________________
(Figure) (Words)

We understand that the above membership declaration is true and correct and that such
declaration is made for purposes of membership dues payment as per JCP Amended By-Laws (Art. XIII,
Sec. 6)

Please find the attached list of officers and members (JCIP Form No. 10-B). Thank you.

CERTIFIED CORRECT:

___________________________ ___________________________
(Signature over Printed Name) (Signature over Printed Name)
LO Secretary LO President
Date: Date:

Address:
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________

DEADLINE: MUST BE RECEIVED BY JCIP SECRETARIAT ON OR BEFORE MIDNIGHT OF May 31, 2022.
FORM #3B

Junior Chamber International Philippines

Developing Leaders for A Changing World
14 Don A. Roces Avenue, Brgy. Paligsahan, 1103 Quezon City
Telephone No. (02) 8373-4138
E-mail: NOM@philjaycees.com Website: www.jciphilippines.com

2022 LOCAL MEMBERSHIP LIST

Note: This form must be attached with the JCP Form #3A (LOM Membership Declaration). Please
use a separate sheet if necessary.

Date: _______________________

Name of Local Organization____________________________ Region:____________ Area:_____________

List of Paid Members (in alphabetical order). Year ____________________

NAME POSITION JCP ID NUMBER OCCUPATION BIRTHDAY MAILING ADDRESS

____________________ _____________ __________ ___________ ________ ________________________

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____________________ _____________ __________ ___________ ________ ________________________
Note for Voting delegates, please put asterisk (*) before their names.

CERTIFIED CORRECT:

___________________________ ___________________________
(Signature over Printed Name) (Signature over Printed Name)
LO Secretary LO President

Date Accomplished: _________________________

DEADLINE: MUST BE RECEIVED BY JCIP SECRETARIAT ON OR BEFORE MIDNIGHT OF May 31, 2022.