Al Falah Center General Assembly Membership Dues Form

Member Information:
NAME: EMAIL:

STREET ADDRESS: PHONE:

CITY, STATE, ZIP:

 FAMILY MEMBERSHIP ($300)  INDIVIDUAL MEMBERSHIP ($100)

ADDITIONAL FAMILY MEMBER NAMES (must reside at same address):
1. ______________________________________________________
 FINANCIAL HARDSHIP WAIVER
2. ______________________________________________________

3. ______________________________________________________

4. ______________________________________________________

5. ______________________________________________________

6. ______________________________________________________

Payment Details: Please note credit card payments incur transaction fees ($3.54
individual and $10.40 family)

CHECK ONE:  CASH  CHECK  VISA  MASTERCARD  OTHER

CARD NUMBER: EXPIRY DATE: SECURITY CODE:

SIGNATURE: TODAY’S DATE: