Membership Form

Membership Form

ISLAMIC CENTER OF BATON ROUGE
- NewRenewal
- Your Name*
  
  First NameLast Name
- Gender*
- Phone Number*
  Please enter a valid phone number.
- Date of Birth*
  
  MonthDayYear
  Date
- Profession*
- State/Driver ID Number*
- Please Upload State/Driver ID*
  
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- Signature of the head of the House member*
  
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- Your Name*
  
  First NameLast Name
- Gender*
- Date of Birth*
  
  MonthDayYear
  Date
- Profession*
- Phone Number*
  Please enter a valid phone number.
- State/Driver ID Number*
- Please Upload State/Driver ID*
  
  Cancelof
- Signature of the head of the House member*
  
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- Your Name*
  
  First NameLast Name
- Phone Number*
  Please enter a valid phone number.
- Date of Birth*
  
  MonthDayYear
  Date
- Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- State/Driver ID Number*
- Please Upload State/Driver ID*
  
  Cancelof
- Family Member 2
- Name*
  
  First NameLast Name
- State/Driver ID Number*
- Date of Birth*
  
  MonthDayYear
  Date
- Phone Number*
  Please enter a valid phone number.
- Please Upload State/Driver ID*
  
  Cancelof
- Family Member 3
- Name
  
  First NameLast Name
- Date of Birth
  
  MonthDayYear
  Date
- State/Driver ID Number
- Phone Number
  Please enter a valid phone number.
- Please Upload State/Driver ID
  
  Cancelof
- Family Member 4
- Name
  
  First NameLast Name
- Date of Birth
  
  MonthDayYear
  Date
- State/Driver ID Number
- Phone Number
  Please enter a valid phone number.
- Please Upload State/Driver ID
  
  Cancelof
- Signature of the head of the House member
  
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- Membership Type
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  Individual:
  One time
  
  $25.00
  
  
  
  Student:
  $15.00
  
  
  
  Family
  $40.00
  
  
  
  Family Lifetime Membership
  $5,000.00
  
  
  
  Total
  
  $0.00
- Important Information (Please Read Carefully):
- 1. A regular member must be a Muslim.
  2. A regular member must be at least 18 years old.
  3. A regular member must be a resident of East or West Baton Rouge Parish, Ascension Parish, Livingston
  Parish, Iberville Parish, Pointe Coupe Parish, East & West Felicana Parish.
  4. A regular member, to be eligible to vote in any election, shall have been a member for a minimum
  of three months prior to any such election and shall have paid the required dues a minimum of one
  month prior to the actual election.
  5. A life member shall be any Muslim who has provided significant and noteworthy service to the Islamic
  community of Baton Rouge is designated as such by a majority vote of the board of directors and has
  made a lump sum donation of $5,000 or more to ICBR or Brighter Horizon School of Baton Rouge.
  
  Yes I have read the above statements and certify that all the information in my application is true and accurate to the best of my
  knowledge by affixing my signature below.
- Should be Empty:

Membership Form

Family Member 2

Family Member 3

Family Member 4

Important Information (Please Read Carefully):