JCRC Council Contact Information

Title

First name

M.I.

Last name

Your name, as you would like it to be listed (if different from above):

Spouse/Partner name, if applicable:

Pronouns (e.g. she/her/hers):

If other, please indicate preferred pronoun below

Birth Date:

Home Address

Home Street

City/Town

State

Zip Code

Work Address

Company/Organization

Street Address

City/Town

State

Zip Code

Preferred address:

HomeWork

Telephone number (home)

Telephone number (work)

Telephone number (mobile)

What is your preferred phone number?

HomeWorkMobile

Personal email address

Work email address

What is your preferred email address?

PersonalWork

Twitter handle

Synagogue/Minyan, if applicable:

Synagogue/Minyan Name

City/Town

Assistant Information, if applicable:

Assistant Name:

Assistant Email

Assistant Phone