Hajj 2012 Registration Form

NOTE: only legal US residents with valid visas can apply.

Fields marked with red *asterisk are mandatory

PLEASE PRESS “SUBMIT” BUTTON “ONCE” ONLY!

HAJJ 2012 REGISTRATION FORM

Assalamoalikum Wa Rehmatullahi Wa Baraktuhoo.

This is the registration form required in order to begin your Hajj application process. Please fill it out completely and make sure all information is correct to the best of your knowledge.
JazakAllah Khair.

Name*

First
Last

Please enter your legal first and last name.

Gender*

Your Age *

Choose your age range

Country of Birth*

Choose the country where you were born

Your address of residence in USA:*

Street Address
Address Line 2
City

State
Zip Code

Enter your complete permanent address in the USA.

Email Address*

Enter Email
Confirm Email

Enter the email address you regularly use to stay up to date on Hajj related activites and communications.

Cell Phone Number*

enter your main cell phone number

Home Phone Number

enter your home phone number in case there is problem reaching you on your cell.

Country of Nationality*

choose the country of your nationality (country of your passport).

Passport Expiration Date*

Choose the exact date of expiration for your passport in mm/dd/yyyy format.

Are you the Mehrum?*

Choose “yes” if your are the Mehrum

Do you have dependents going to Hajj with you?*

Choose “Yes” if there will be dependents (ex: family members etc.) going to Hajj with you. Otherwise choose “No”

Dependents' Information :*

Please enter data about EACH of your dependents in the following format (If you have more than one dependent, please give a space between each dependent): ——————-> FIRST NAME ,
LAST NAME ,
RELATIONSHIP TO MEHRUM ,
COUNTRY OF DEPENDENT’S BIRTH ,
COUNTRY OF DEPENDENT’S NATIONALITY

Total Number of Dependents:*

please enter the total NUMBER of dependents whose information you have provided above.

Additional Comments/Notes – (Optional)

you may enter brief notes or information that is relevant to this application.

Please Press the SUBMIT button "ONCE" only.

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Hajj 2012 Registration Form

HAJJ 2012 REGISTRATION FORM

Please Press the SUBMIT button "ONCE" only.

CLICK HERE TO VIEW DOCUMENTS REQUIRED FOR HAJJ