NHIC Membership Registration Form

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STEP 1: Please choose a membership type. *

Associate: I am under 18 years old, not from this community, or rarely attend the Masjid. I understand that I cannot vote in a General Assembly or run for office.

Member: I am 18+ years old, a legal resident, regularly in the Masjid, known by the Imam or the committee. Members have the right to vote at a General Assembly and to run for office.

STEP 2: Fill in your personal information.

Gender *

Brother

Sister

First Name: *

Last Name: *

Cell Phone #: *

Email: *

Street Address: *

City: *

State: *

Zip: *

Spouse First Name: *

Spouse Last Name: *

Spouse Cell Phone #: *

Spouse Email : *

Emergency Contact other than spouse: *

Relationship: *

Phone #: *

Children’s Information:

1st Child:

Boy

Girl

Clear selection

First Name:

Last Name:

Child’s Date of Birth:

YYYY

2nd Child:

Girl

Boy

Clear selection

First Name:

Last Name:

Child’s Date of Birth:

YYYY

3rd Child:

Girl

Boy

Clear selection

First Name:

Last Name:

Child’s Date of Birth:

YYYY

4th Child:

Girl

Boy

Clear selection

First Name:

Last Name:

Child’s Date of Birth:

YYYY

5th Child:

Girl

Boy

Clear selection

First Name:

Last Name:

Child’s Date of Birth:

YYYY

6th Child:

Girl

Boy

Clear selection

First Name:

Last Name:

Child’s Date of Birth:

YYYY

STEP 3: References

ONLY applicants seeking membership must complete this step. Associates can skip to Step 4.

Provide References:

List the individuals we will contact to confirm your status. Official NHIC Sheikh, two Community Members, or two Executive Committee Members.

Official Masjid Sheikh Full Name:

=========================== OR ==========================

Community Member #1 Full Name:

Community Member #1 Phone Number:

Community Member #2 Full Name:

Community Member #2 Phone Number:

=========================== OR ==========================

Executive Committee #1 Full Name:

Executive Committee #1 Phone Number:

Executive Committee #2 Full Name:

Executive Committee #2 Phone Number:

Privacy:

Check box if you do not want your phone number to be included in our database to receive NHIC urgent Masjid text messages only.

Check box if you do not want your email to be included in our database to receive NHIC e-news and Masjid announcements.

STEP 4: Sign & Submit Your Form

By signing this application, I agree to abide by the NHIC By-laws otherwise my membership may be revoked. I confirm that the information I have provided is correct. I accept that any false information that I have provided will invalidate this application.

I understand that by typing my full name below, I am officially signing this application. *

Date: *

YYYY

Submit

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