TEST MEMBERSHIP

Member Details

Please create a username and password to be able to access your data and make the necessary updates in the future.

Title:

First Name:

Last Name:

Address:

City:

State:

Zip Code:

Tel #:

Home:

Work:

Cell:

Fax:

Email:

Password

Confirm Password

Hebrew Name:

Date of Birth:
The day and night selection is only in case you have selected the date IN ENGLISH in the calendar.

Born during:

Day Night

(Please indicate day/night for birthdays as this affects the Hebrew date)

Father's Name:

Mother's Full Name:

Mother's Maiden Name:

Maternal Grandmother’s Hebrew Name:

First

Last

Cohen Levi Israel

Jewish by Birth Converted

Occupation

Ashkenazi Sephardic

Marital Status

Single Married Divorced Widowed

Anniversary Date:

If divorced, do you have a Jewish “Get”?:

If any family is converted, please explain:

Prior Shul Affiliation:

Rabbi’s Reference:

Children

Full Name/s: Born during the:
The day and night selection is only in case you have selected the date IN ENGLISH in the calendar. Day Night

Please indicate day/night for birthdays as this affects the Hebrew date.

Nachalot/Yahrtzeits

Hebrew Name: Surname: Mother/Father's name or both: Died during the:
The day and night selection is only in case you have selected the date IN ENGLISH in the calendar. Day Night Relationship:

Additional Details

Emergency Contact Name:

Tel:

Second residence mailing address:

Tel Number:

Jewish Marriage Certificate (Ketuvah) :

Certificate of Conversion :

Jewish Divorce Certificate (Get) :

Payment Information

New Member Renewal

Standard Membership

Individual ---------------- $260 annually

Family ---------------- $260 annually

Membership dues are billed annually and are due by Rosh Hashana that year. High Holiday Seats are not included.

Please find enclosed a check in the amount of $ Please mail your check along with updated applicant form to: I authorize the Hechal Shalom to charge my credit card $ Card # Exp Date CVV Code Signature

Monthly Yearly

Membership is renewed each year unless you notify us otherwise. All contributions are tax deductible to the fullest extent allowed by law.
For Further Information, Please Contact:

0000000000000

We reserve the right of granting membership pending review of application and pertinent documents.

Member Details

Address:

Tel #:

Spouse Details

Address:

Tel #:

Marital Status

Children

Nachalot/Yahrtzeits

Additional Details

Payment Information

Standard Membership

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Family

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