SECTION I | Your Information
Last Name
First Name
Hebrew Name
Father's Hebrew Name
Mother's Hebrew Name
Occupation
Birth Date [DD / MM / YYYY]
 
 		 Day
Night		 Jewish by
Birth Converted		 I am a
Cohen Levi Israel
Cell Phone
Work Phone
Email
SECTION II | Spouse's Information
Last Name
First Name
Hebrew Name
Father's Hebrew Name Mother's Hebrew Name Occupation
Birth Date [DD / MM / YYYY]
Day
Night		 Jewish by
Birth Converted		 I am a
Cohen Levi Israel
Cell Phone
Work Phone
Email
SECTION III | Personal Information
Address
City/State/Zip
Home Phone
Marital Status: Single Never been Married Married Divorced Widowed
Anniversary Date [DD / MM / YYYY]
Divorce Date [DD / MM / YYYY]
If divorced, do you have a Jewish Get?
Yes   No		 Who was Get administered by?
Widowed Date [DD / MM / YYYY]
SECTION IV | Children
Child 1 Male Female Name
Hebrew Name
Birth Date [DD / MM / YYYY]
/  / 		Day Night School
Child 2 Male Female Name
Hebrew Name
Birth Date [DD / MM / YYYY]
/  / 		Day Night School
Child 3 Male Female Name
Hebrew Name
Birth Date [DD / MM / YYYY]
/  / 		Day Night School
Child 4 Male Female Name
Hebrew Name
Birth Date [DD / MM / YYYY]
/  /   		Day Night School
Child 5 Male Female Name
Hebrew Name
Birth Date [DD / MM / YYYY]
/  / 		Day Night School
Child 6 Male Female Name
Hebrew Name
Birth Date [DD / MM / YYYY]
/  / 		Day Night School
Child 7 Male Female Name
Hebrew Name
Birth Date [DD / MM / YYYY]
/  / 		Day Night School
Child 8 Male Female Name
Hebrew Name
Birth Date [DD / MM / YYYY]
/  / 		Day Night School
  Are any children adopted?
Yes No		 If yes, give details, including any conversion info:
SECTION V | Yahrzeits
Name
[English / Hebrew / Father's Hebrew / Last]		 Date of Passing [DD / MM / YYYY]

Day
Night		 Relationship
Name

[English / Hebrew / Father's Hebrew / Last]		 Date of Passing [DD / MM / YYYY]
Day
Night		 Relationship
Name

[English / Hebrew / Father's Hebrew / Last]		 Date of Passing [DD / MM / YYYY]
Day
Night		 Relationship
Name

[English / Hebrew / Father's Hebrew / Last]		 Date of Passing [DD / MM / YYYY]
Day
Night		 Relationship
Name

[English / Hebrew / Father's Hebrew / Last]		 Date of Passing [DD / MM / YYYY]
Day
Night		 Relationship
Name

[English / Hebrew / Father's Hebrew / Last]		 Date of Passing [DD / MM / YYYY]
Day
Night		 Relationship
Section VI | Membership Opportunities
All Membership fees can be made in one payment or in 2 installments
Please select the option of your choice:
  Annual Bi-Annual
Family $800 $400
Single $400 $200
Section VII | Building Renovation Fund
Please, help us build the future and expand our horizons! We encourage your participation in our building renovation fund. Your donation will go toward the following projects: new floors throughout the building, air conditioning system in the shul, new boys and girls rest rooms with a washing area in hallway, and total paving of the outside of our building. Your family contribution of $5,000 can be made in one single payment or in installments.
1 payment of $5,000 12 monthly installments of $416 Would you like us to contact you to discuss further sponsorship opportunities?
Yes No
24 monthly installments of $208 36 monthly installments of $138
Section VIII | Payment Authorization

I would like to make a one time payment. Please charge my card below.
I would like make recurring payments. Please charge my card below on the first of every month.
Total Amount Pledged - Membership
$ 		Total Amount Pledged - Building Fund
$ 		 
Comments/Special Requests
Amount to be charged TODAY
[First recurring payment or one time amount]
$ 		Card Type
Card Number
Expiration Date
Card Security Code
I hereby certify that all information given above is true and correct and that I, and all members of my immediate family named herein, are Jewish by birth, or by conversion in accordance with Orthodox Jewish Law (Halacha).
Signature: Husband Wife