Gujarati Samaj Chicago Membership FormRM_Stats First Name *Last Name *Date of Birth *Spouse NameSpouse Date of Birth Name of Children 1 (Under 18)Date of Birth 1Name of Children 2 (Under 18)Date of Birth 2Name of Children 3 (Under 18)Date of Birth 3Name of Children 4 (Under 18)Date of Birth 4 Street Address State or Region AL AK AZ AR AA AE AP CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Email *Phone Number *Membership Fees *Select an optionLife Membership ($ 251)Senior Citizen 65 & Above ($ 151)Annual Family ($ 50)Annual Single ($ 35)Annual Memberships end on December 31st of the membership year. Do you agree with our terms and conditions? *Yes, I agree.I am undersigned understand that this membership application will be reviewed by the membership committee of Gujarati Samaj Chicago for approval. I understand that ONLY after such an approval, the membership will be final. Above information is true and correct to the best of my knowledge. I understand that any misrepresentation or falsification will result in cancellation of the membership and I will be responsible for guest fees if the members was used during any of our programs such as Diwali Dinner, Navaratri Garba, Picnic and other events. Please Note: Annual Memberships end on December 31st of the membership year. Select a payment method * Pay Offline Note: It looks like JavaScript is disabled in your browser. Some elements of this form may require JavaScript to work properly. If you have trouble submitting the form, try enabling JavaScript momentarily and resubmit. JavaScript settings are usually found in Browser Settings or Browser Developer menu.