Islamic center of Davis 539 Russell Blvd, Davis, CA, 95616. Tel: (530) 756-5216 www.davismasjid.org email: [email protected]

Membership Application Full Name: ____________________________________________ Birthdate (mm/dd/yyyy): ______/_______/____________________ City of Residence: ____________________ County: ____________ Contact Telephone Number: ______________________________ Contact Email Address: __________________________________ Residency documentation: ________________________________ (Include a copy of CDL, utility bill, first page of lease contract, or another document to verify you residential address) Would you be willing to accept a nomination for an EC position: [ ] Yes [ ] No Signature: ________________________ Date: ____________________ For non-residents of Yolo County, please provide the name and contact information of two Members as references: Reference 1 Full Name: ___________________________________ Reference 1 Phone number: ________________________________ Reference 2 Full Name: ___________________________________ Reference 2 Phone number: ________________________________ (A list of member names will be published in the display case in the Masjid lobby) ___________________________________________________________________ EC Recommendation: Membership Accepted [ ] Yes

[ ] No

Reason for denial: ____________________________________________ ____________________________________________________________ Date: _____________________