Application-for-Membership (15)

New Membership Form

Wegene Lene Edir
10942 West 74th Terrace,
Shawnee, KS 66203

Email: Info@lewegeneleneedir.com
Phone number: (913) 329-4903

Membership ID

Family Size*

Applicant Full Name*

Spouse

Address *

City*

State*

Zip*

Cell Number *

Spouse Cell Number

Email*

In the table below, list the family members who are residents of the household. Any person over age 26 years of age living in household, they should fill this form separately for themselves.

Numbers of Children under 26 years of age*

Names of Children under 26 years of age:

Rows	Name	Date of Birth:
1.
2.
3.
4.

Names of Parents leave with you not working, if they have a job they should fill this form separately for themselves.

Rows	Name	Date of Birth:
1.
2.

Emergency contact Full Name

Email

Phone

Format: (000) 000-0000.

As a new member, I fully agree and abide by the Bylaw of WLE. I hereby apply for membership and pledge to fully adhere to the Administrative Regulations, Bylaws of WLE and understanding the six months probation time before receiving benefits. I also certify that the information provided above is true and correct.

Applicant’s Signature

Date

One time membership registration fee for couples and individuals $300 and Onetime Advance payment couples $60 and individuals $30 - All applicants pay this fee.