Membership Form

Membership Registration

Complete the official membership form below to join Habesha Support LV Center.

Member Information

Full Legal Name

Date of Birth

Gender

Male

Female

Prefer Not to Say

Residential Address

Apartment/Unit #

City

State

ZIP Code

Email Address

Phone Number

Preferred Method of Communication

Phone

Text

Membership Donation

Choose one of the payment methods below to complete your membership.

Zelle

Send to lvsupport1@gmail.com

Bank Transfer

Bank: Wells Fargo
Account name: Habesha Support L.V. Center
Routing # (direct deposit & electronic): 321270742
Routing # (domestic wire): 121000248
SWIFT/BIC (international): WFBIUS6S

For domestic and international bank transfers, please contact us at lvsupport1@gmail.com for secure transfer instructions.

Please include your full name as the payment reference so we can match your donation to your membership.

Beneficiary Information

A person designated to receive membership benefits or organizational support on your behalf in the event of illness, emergency, incapacity, or death.

Beneficiary Full Legal Name

Beneficiary Address

City

State

ZIP Code

Phone Number

Member Acknowledgement & Authorization

I certify that the information provided is true and accurate to the best of my knowledge. I understand that membership with Habesha LV / Las Vegas Habesha Support Center is subject to organizational guidelines and policies. I acknowledge that the beneficiary listed above is my designated beneficiary for membership-related support or benefits, where applicable.

I have read and agree to the acknowledgement above.

Member Signature (type full name)

Date