| Back |
Please print this application, fill it, and submit it at CIMIC.
I, the undersigned, request membership in the Association of the Central Illinois Mosque & Islamic Center (CIMIC). I certify that I am a Muslim, and I reside within the counties served by CIMIC. I agree to abide by the CIMIC constitution and all CIMIC regulations, and policies. I understand that, if I am granted regular membership, I shall only become a voting member six months after the date my membership is granted. I also understand that I must maintain eligibility and current membership records and payment of dues in order to retain my status as a voting member.
| Signatue: _____________________________ | Application Date: __________________________ |
| Last Name, First Name _____________________________ |
Occupation or field of study ___________________________ |
| Address _____________________________ |
City, State, Zip code ___________________________ |
| Tel. No. _____________________________ |
E-Mail ___________________________ |
| Country of Origin _____________________________ |
US Citizen? [ ] Yes [ ] No |
| Would you like your name to be published in the CIMIC directory? [ ] Yes, [ ] No. |
| Would you like to subscribe to CIMIC mailing list? [ ] Yes, [ ] No. |
| Children's names and ages (under 18 years of age):
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| Your help is needed, please check area of interest: |
| Outside Maintenance | Special Projects | ||
| Masjid Cleaning | Social | ||
| Masjid Maintenance | Fund Raising | ||
| Women's Committee | Da'wa | ||
| Library | Publications & Communications | ||
| Islamic School | Other (Specify) |
For official use only, do not write below this line.
| 1999 | 2000 | 2001 | 2002 | 2003 | 2004 | 2005 | 2006 | |
| Dues paid | ||||||||
| Date received | ||||||||
| Received by |