Imam al-Asr Masjid Membership Form

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Please provide the information below. Our privacy policy.

Email *

Membership Type *

Individual

Family

AFFIRMATION *

I affirm that I am a Shia Ithna-Ashari Muslim, and I will abide by the constitution and by-laws of the Center. https://www.imamalasr.org/wp-content/uploads/2021/10/Bylaws.pdf

Required

MEMBER INFORMATION

Name *

Phone *

Address

Age *

Profession

Are you the head of hoursehold? *

Yes

Name of head of the household if different than your name.

SPOUSE INFORMATION

Name

Phone

Profession

CHILDREN INFORMATION

Child 1: Name

Child 1: Gender

Child 1: Age

Child 2: Name

Child 2: Gender

Child 2: Age

Child 3: Name

Child 3: Gender

Child 3: Age

Child 4: Name

Child 4: Gender

Child 4: Age

Child 5: Name

Child 5: Gender

Child 5: Age

Other Children Information

REFERENCES

Please provide two references who can support your membership application. Your references must be Shia Ithna-Ashari Muslims, and ideally should be existing members of Imam al-Asr Masjid.

Reference 1: Name

Reference 1: Phone

Reference 1: Email

Reference 2: Name

Reference 2: Phone

Reference 2: Email

MEMBERSHIP DUES

Membership is due annually. For more information on membership amount and payment options, please visit our website https://www.imamalasr.org/membership

Have you paid the membership dues? *

Yes, I already paid

No, I will be paying later

Other:

NEWSLETTER SUBSCRIPTION

Would you like to receive our email newsletter? *

Yes

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