Membership Application Applicant Information Name * First Name Last Name Email * Date of birth MM DD YYYY Place of birth Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country University Major/Minor Emplyment Information Current Organization Organization Number (###) ### #### Position How Long? Organization's Address Address 1 Address 2 City State/Province Zip/Postal Code Country Other Information What language Do you speak? In what language do you deliver your khutba? Do you have health insurance? Yes No Membership Fee $120 Payment Method In person payment (cash / check) Mail in payment (check) Online payment (credit card / Paypal) By checking this, I agree to the terms and conditions of the membership. * I agree Date of application MM DD YYYY Thank you!
