Member Details Please create a username and password to be able to access your data and make the necessary updates in the future. Title: Mr. Mrs. Rabbi Miss Dr. First Name: Last Name: Address: 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 Spouse Details Title: Mr. Mrs. Rabbi Miss Dr. First Name: Maiden Name: Last Name: Address: SAME AS ABOVE: Address: City: State: Zip Code: Tel #: Home: Work: Cell: Fax: Email: 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 Marital Status Single Married Divorced Widowed Anniversary Date: If divorced, do you have a Jewish “Get”?: Select Yes No In Process If any family is converted, please explain: Prior Shul Affiliation: Rabbi’s Reference: Children Add 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 Remove Please indicate day/night for birthdays as this affects the Hebrew date. Nachalot/Yahrtzeits Add 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: Remove 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. Family $260