New Membership ~ MOHID ©

Please use Member portal to renew your membership if you are an existing member.

Primary Member Infomation

First Name *

Last Name *

Phone Number *

Cell Number

Email Address *

Confirm Email Address *

Company Name

Date of Birth *

Gender*

Address1 *

Address2

Country *

State *

City *

Zip Code *

Household Membership Type is not available in provided Zip code. Please select another Membership Type or change your Zip code.

Native Country

Citizenship Type

US Citizen Not a US Citizen

Marital Status

Add Family/Group Information

Group Member Type *

First Name *

Last Name *

Phone Number *

Cell Number

Email Address *

Confirm Email Address *

Company Name

Date of Birth *

Gender*

Same as Primary Member

Address1 *

Address2

Country *

State *

City *

Zip Code *

Household Membership Type is not available in provided Zip code. Please select another Membership Type or change your Zip code.

Native Country

Citizenship Type

US Citizen Not a US Citizen

Marital Status

+ Add Another Family/ Group Member

Add Children Information

Use this section if you want to add (minor) children records. These records will not be added as members in the system.

First Name*

Last Name*

Phone Number

Email Address

Child Year of Birth

+ Add Another Child

Membership Type *

About Membership:

This membership category is for Households that wish to be voting members of ICP (ages 18+). The Head of Household should be the main member, and each additional member must be entered. $4/mo per member.

Select Membership Duration

Membership Period(s)

Membership Fee Type *

Before submission, please review the provided information to avoid typing mistakes.

Member(s) Information:

Name	Phone	Email	Address	Relation	Gender	Date of Birth	Marital Status	Native Country	Citizenship Type

Children Detail(s):

Name	Phone	Email	Year of Birth

Membership Detail(s):

Membership Type:

Validity:

Membership Start Month	Membership Join Date	Membership End Date

Fee Detail(s):

Fee Type	Fee Amount Per Member	No. of selected Periods

Amount Per Member For Selected No. of Periods	Total Members	Total Amount Due

Payment

You can help save us on credit card transaction fees by selecting the eCheck/ACH option. Jazak'Allah!

Payment Method

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Credit/Debit Card

Bank Name

Name on Account *

Account Number*

Routing Number*

Account Type*

Monthly Recurring

Consent * Do you give Islamic Center of Pittsburgh consent to authorize electronic fund transfer from the account specified for this transaction in the amount specified.

Agree Decline

Since you purchased free Ticket No Payment Required.

Comments

Round up amount to {round_up_amount} to cover transaction charges that will be incurred by the Masjid

Payment Information:

Total Amount Due

Amount Paying

Recurring Information

Auto Renewal if this option is enabled ,then System will save this Payment information as default payment method for this Member and will automatically renew this membership on the day after the membership expires.

Islamic Center of Pittsburgh

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Primary Member Infomation

About Membership:

Member(s) Information:

Children Detail(s):

Membership Detail(s):

Validity:

Fee Detail(s):

Payment

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Payment Information:

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Islamic Center of Pittsburgh

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Primary Member Infomation

Declaration

About Membership:

Member(s) Information:

Children Detail(s):

Membership Detail(s):

Validity:

Fee Detail(s):

Payment

Promotions

Payment Information:

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