Membership Form

Life MembershipFee : $250.00 (For the spouse add $1.00)

Your Name: *

Email Address 1:

Occupation:

Home Address: *

Home Number *

Mobile Phone: *

Father’s Name:

Emergency Contact: *

Associate Membership-For 2 yearsFee : $50.00 (For the spouse add $1.00)

Spouse’s Name:

Email Address 2:

Occupation:

Mailing Address: *

Work Number

Native Place in India:

Mother’s Name:

Emergency Phone#: *

Add to email list:YesNo

Children’s Name and Ages:

Please give 2 references (Preferably JCLA/JCSC Life Members).
Applicant should be Jain or at least one of the parents, should be Jain.

Reference 1:

Name: *

Phone: *

Street Address *

Reference 2:

Name: *

Phone: *

Address: *

Honorary Membership

Please make checks payable to :

Jain Center of Los Angeles.

Check #

Amount $

USD

Mailing Address:

550 S. Hill Street, Suite 1183, Los Angeles, CA 90013-2414

By signing below I agree to abide by the rules and regulations of Jain Center of Los Angeles.

Signature: *

Date: *

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