Membership Form of Individual

Membership Form of Individual

ISLAMIC CENTER OF BATON ROUGE

Are you renewing the membership or applying for new membership ?
Your Name

First NameLast Name
Gender
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearAge must be 18+
Profession
State/Driver ID Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please Upload State/Driver ID

Cancelof
Signature of the head of the House member

Membership Type

Individual:

One time

$25.00

Total

Credit Card

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: