Membership Registration

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Email *

Last Name *

First Name *

Middle Name

What is your membership status? *

New

Renewing (existing)

Gender *

Male

Female

Address - Street *

City *

State *

Zip Code *

Phone Number - Home

Phone Number - Cell/Work Phone *

Profession/Line of Business

Marital Status

Married

Single

Other:

Clear selection

If married, full name of spouse

Language Fluency:

Very Fluent

Fluent

Not Fluent

Afaan Oromo

English

Other

Membership Fee

The registration fee is $20.00 (twenty dollars). The membership fee is $15.00 (fifteen dollars) per month. Members are encouraged to pay quarterly, semi-annually or annually. Payment could be made on the next page once you submitted this form.

Registration & Membership Fees *

Registration + 3 Months membership = $65.00

Registration + 6 Months membership = $110.00

Registration + 12 Months membership = $200.00

Signature - Enter Your Full Name *

Date *

YYYY

Send me a copy of my responses.

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