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Contact Information
The Bosnian Islamic Cultural Center is in the process of collecting member's contact information. The intent is to build a centralized database of essential household demographics to improve our communication efforts and facilitate a better member experience. At your convenience, please complete the short questionnaire below.
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Title *
First Name *
Last Name *
Date of Birth *
MM
/
DD
/
YYYY
Street Address *
City *
State *
Zip Code *
Phone Type *
Phone Number (xxx-xxx-xxxx) *
Email *
Are you a member of any of the following groups?  (Please check all that apply. If none, please leave blank.)
Title
Spouse First Name
Spouse Last Name
Spouse Phone Type
Clear selection
Spouse Phone Number (xxx-xxx-xxxx)
Spouse Date of Birth
MM
/
DD
/
YYYY
Spouse Email
Is your spouse a member of any of the following groups?  (Please check all that apply. If none, please leave blank.)
Do you have children in your household? *
First Name (Child #1. If not applicable, please skip the question.)
Last Name (Child #1. If not applicable, please skip the question.)
Date of Birth (Child #1. If not applicable, please skip the question.)
MM
/
DD
/
YYYY
Does Child #1 attend either of the following? (Please check all that apply. If not applicable, please skip the question.)
First Name (Child #2. If not applicable, please skip the question.)
Last Name (Child #2. If not applicable, please skip the question.)
Date of Birth (Child #2) - If not applicable, please skip the question.
MM
/
DD
/
YYYY
Does Child #2 attend either of the following? (Please check all that apply. If not applicable, please skip the question.)
First Name (Child #3. If not applicable, please skip the question.)
Last Name (Child #3. If not applicable, please skip the question.)
Date of Birth (Child #3. If not applicable, please skip the question.)
MM
/
DD
/
YYYY
Does Child #3 attend either of the following? (Please check all that apply. If not applicable, please skip the question.)
First Name (Child #4. If not applicable, please skip the question.)
Last Name (Child #4. If not applicable, please skip the question.)
Date of Birth (Child #4. If not applicable, please skip the question.)
MM
/
DD
/
YYYY
Does Child #4 attend either of the following? (Please check all that apply. If not applicable, please skip the question.)
Please indicate your membership type *
Please provide any additional comments and feedback below.  For any specific questions, please contact us at info@bicc-chicago.com
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