Membership Type*:

PRIMARY APPLICANT INFORMATION

Title*:
First Name*:

Last Name*:
Age*:

Email*:
Mobile*:

Occupation:
Qualification:

ADDRESS & CONTACT INFORMATION

Address*:
City*:

Postal Code*:
Home Phone:

SPOUSE INFORMATION

Title*:
First Name*:

Last Name*:
Age*:

Email*:
Mobile*:

CHILDREN(UNDER 18) INFORMATION

No. of Children:

Name*:
Age*:

Name*:
Age*:

Name*:
Age*:

Name*:
Age*:

Name*:
Age*:

Name*:
Age*:

REFERENCES INFORMATION

Active Member Name*:
Phone*:

Active Member Name*:
Phone*:

Active Member Name*:
Phone*:

As per Hussainia’s Constitution Article 6, Section 2, Active Member, is a Shia Ithna-Ashari Muslim with Fiqah-e-Jafaria ideology of practices, who has been in good standing (in dues) for minimum period of two consecutive years. An aspiring new member must be nominated by 3 Active members.

*Every individual who wants to become Hussainia’s active member must have to get the following section filled by contacting 3 current active members of the Association*

Additional Information