Membership Form

NOTICE: This system is intended for online credit / debit card payment ONLY. If you would like to pay by cash or check, please click here to download the form and mail completed form along with payment to: India Association of Long Island Inc. 366 North Broadway. Suite 410. Jericho, NY 11754
Membership Form
Full Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Spouse's Full Name

First NameMiddle NameLast Name
Phone Number (home)

Area CodePhone Number
Phone Number (cell/work)

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Membership Options
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Life Membership Family$275.00

Senior Life Member with proof of age (above age 65)$150.00

Annual Membership$50.00

Conversion of Annual Membership to life Membership with 60 days from expiration$225.00

Single Life Membership $150.00

Single Senior Life Member with proof of age (above age 65)$100.00
Date of enrollment

MonthDayYear
Referred by

First NameLast Name
Do you want to be listed as members on the IALI website?
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