SIIJLA Membership Application Form

LOS ANGELES JAMAAT - SIIJLA

SHIA ITHNASHERI ISLAMIC JAMAAT OF LOS ANGELES - 7925 SERAPIS AVE PICO RIVERA, P.O. BOX 1207, CA 90660 Tel: 1-562-942-7442
General Membership Info

To apply for membership, please complete all questions below and submit your application. Should you have any questions, please contact the SIIJLA Secretary at nazneenn@gmail.com.
Name

First NameLast Name
Spouse Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Cellular Number

Area CodePhone Number
Home Number

Area CodePhone Number
Children under 18 years of age
Child Full Name
Child Birthdate

MonthDayYear
Child Full Name
Child Birthdate

MonthDayYear
Child Full Name
Child Birthdate

MonthDayYear
Child Full Name
Child Birthdate

MonthDayYear
Member Attestation

I agree to abide by the rules and regulations as laid down in the Jamaat’s constitution and any amendments that may be made from time to time. (Constitution can be found at www.lajamaat.org)
SIIJLA Membership Fees
Adult $150.00 per year

Seniors $75.00 per year

Students $75.00 per year

Fees can be paid online at www.lajamaat.org or by bringing your check to the center
Member Proposal Attestation

We the undersigned, propose this applicant for membership of SIIJLA. To the best of our knowledge, the applicant is a person worthy of membership of SIIJLA.
Proposed By

First NameLast Name
Proposed By

First NameLast Name
Should be Empty:

LOS ANGELES JAMAAT - SIIJLA