LIBERIAN COMMUNITY ASSOCIATION OF CONNECTICUT

MEMBERSHIP REGISTRATION

FIRST NAME:

LAST NAME:

STREET:

CITY:

STATE:

ZIP CODE:

HOME PHONE:

CELL PHONE:

EMAIL:

BIRTH MONTH:

BIRTH YEAR:

COMMENTS (OPTIONAL):

REGISTRATION FEE $10.00:

By completing this on line form, you've made a committment to become a member of the Liberian Community Association. All information given becomes the property of the Liberian Community Association of Connecticut and shall not be shared with a third party. All information given will be used for the association purpose ONLY.

For any further questions, please contact Mrs. Assuntha Nimely-Phillips Membership committee Chairlady- 203-430-1724

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