Membership Request Form Thank you for your interest in joining the Muslim American Society. Your application will be pending review. Once approved, you will be notified and your card will be charged. You will receive a receipt via email. Personal Information Mr./Mrs. First Name* Middle Name Last Name* Gender* Select Female Male Date of Birth* Contact Information Email Address* Phone Number* Address* City* State* AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip Code* Membership Information Chapter to Join* --Select--No preferenceAtlantaAustinBay AreaBirminghamBostonCentral South New JerseyCharlotteChicagoCincinnatiColoradoColumbusConnecticutDallasDetroitHouston, TXIowaKansas CityLafayette, LAGreater Los Angeles, CAMarylandMemphisMilwaukee, WIMinnesotaNew JerseyNew OrleansNew YorkOklahoma CityOrlando, FLPanama CityPhiladelphiaPhoenixPittsburghPortlandRaleighSouth FloridaSacramentoSan AntonioSan DiegoSeattleSyracuseTampaUrbana-ChampaignWashington DC Membership Dues Amount* $ Monthly Annually Minimum $10/month or $120/year Payment Information Credit Card Type* VISA Master Card American Express Discover Name on Card* Credit Card Number* Expiration Date* --Select-- 01-January 02-February 03-March 04-April 05-May 06-June 07-July 08-August 09-September 10-October 11-November 12-December --Select-- 2017201820192020202120222023202420252026 Other Information Notes and Comments Accepting Terms* I hereby attest that I'm legal resident of the U.S. and I accept the vision, mission and objectives of the Muslim American Society. I promise to follow the Society’s rules and regulations. I agree to resort to Islamic arbitration in resolving all disputes with the Society and its members. I agree to support MAS in its activities and services. Are you a robot?* Thank you! Your request is being processed now. Please wait...The PAY ONLINE button is disabled to avoid double charges. Submit! Pay with confidence. This form is secure and is SSL certified.