New Customer Registration Form

Islamic Association of Ypsilanti

Request for Zakat
Name*

First NameLast Name
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Number of Family Members at Home*
Country of Origin*
Reference*
Sources of Income (Please fill all that apply):
Work: Amount: $ monthly.
Government Assistance: Amount: $ monthly.
Food Stamps: Amount: $ monthly.
Other: Amount: $ monthly.
Do you rent or own: Monthly mortgage/rent: $
Amount of Savings/Gold: $
If request for rent, please fill out the following:
Landlord's Name

First NameLast Name
Landlord's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Landlord's Phone Number
Please enter a valid phone number.
Comments:
Should be Empty: