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Membership Application & Payment

Membership Application & Payment

FAMILY INFO
Family Name   Address
City, Post Code   Home phone
Business phone   Family Email
Mobile #1   Mobile #2
         
HIS INFO   HER INFO
First Name   First Name
Cohen Levi Yisroel      
Hebrew Name   Hebrew Name
Father's Hebrew Name   Father's Hebrew Name
Mother's Hebrew Name   Mother's Hebrew Name
         
If married,
Date of Marriage
/ /
Day Month Year
  Location of Marriage
Conversion in his family Yes No   Conversion in her family Yes No
If conversions, details:   If conversions, details:
         
Date of Birth / /
Day Month Year
  Date of Birth / /
Day Month Year
 
CHILDREN INFO
First Name Hebrew Name Date of Birth Schools Attended
/ /
Day Month Year
/ /
Day Month Year
/ /
Day Month Year
/ /
Day Month Year
YARTZEIT HIS FAMILY
Full Hebrew Name Full English Name Relationship Date of passing Time of passing

/ /
MM DD YY
  AM
PM

/ /
MM DD YY

AM
PM
YARTZEIT HER FAMILY
Full Hebrew Name Full English Name Relationship Date of passing Time of passing

/ /
MM DD YY
  AM
PM

/ /
MM DD YY
  AM
PM
MEMBERSHIP CONTRIBUTIONS
Please select appropriate category
Type of Membership Family Single Monthly Family Monthly Single
Standard Membership $824 $576 $74 $52
Pensioner or Concession Membership $597 $453 $55 $42

Dependent Child under 18 (includes a Seat) $30 (1 ) $60 (2) $90 (3)
Security Levy - Per Seat $15 (1) $30 (2) $45 (3) $60 (4)

Number of seat's needed: Men Women

     
PAYMENT OPTIONS

Card Type: Visa MC

    Name on Card:

Card No: Exp: /

Are all members of the immediate familiy listed herein Jewish by birth or by conversion, in accordance with Orthodox Halachic Standards? Yes No
I hereby certify that all information given above is true and correct.
Signature   Date / /
Day Month Year

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