| *Honorific: |
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| *Your Full Name: |
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| *Address: |
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| *City: |
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| *State: |
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| *Zip Code: |
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| *County of Residence |
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| *Country: |
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| *I am applying for the following exclusive territory: |
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| *Telephone: |
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| *Best time to call: |
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| *Fax: |
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| *Cell: |
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| *Email: |
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| *DOB: |
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| *Marital Status: |
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| *Spouse Name: |
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| *Spouse's Occupation: |
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| *Children: |
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| *Ages: |
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| *U.S. Citizen: |
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| *Currently Employed: |
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| If Yes, give name and address of employer: |
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| *Educational Background: |
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| *Clubs, organizations, church affiliation, activities, etc: |
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| *Do you have any physical condition which would affect your ability to perform the duties as an NLJC Director? |
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| If yes, please describe: |
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| *In one paragraph, tell why you believe you would be successful as a Director of the National League of Junior Cotillions™ program in your area: |
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| References (Non-related): |
| Personal |
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| *Name: |
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| *Address: |
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| *City: |
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| *State: |
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| *Zip Code: |
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| *Telephone: |
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| Professional |
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| *Name: |
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| *Address: |
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| *City: |
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| *State: |
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| *Zip Code: |
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| *Telephone: |
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| *How did you learn about NLJC? |
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It is my understanding that NLJC will review and verify all data presented on this form prior to my being granted a license to operate an NLJC program. |
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| *I have read and understand the above: |
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| Questions / Comments |
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