Personal Details
Rabbi Dr Mr Mrs Miss
Full Name:
Address:
Postcode:
Telephone:
Email:
Occupation:
Hebrew Name:
Father's Hebrew Name:
Kohen Levi Yisroel
Date of Birth:
Marriage details (If unmarried please give the details of your Parents’ marriage)
Synagogue
Town
Name of officiating Rabbi
Date
Full maiden name of wife
Unmarried children under 21 years of age
Name(s) of Sons/Daughter(s) and Date(s) of Birth
Please give particulars of all YARZHEITS (if any)
Relationship and Hebrew Date
Have you ever been a member of this Beth Hamedrash?	Yes No
Please name any synagogue of which you are currently a member:
BURIAL SOCIETY
I do/not wish to become a member of the burial society:	Yes No
Please name any Burial Society of which you are/have been a member with dates:
I declare that I observe Shabbos:
Please tick the box if you wish to be notified from time to time with email Shul announcents:
Names of two members who are prepared to act as referees: Member1: Member2:
I WISH TO APPLY FOR MEMBERSHIP OF THE CONGREGATION AND AGREE TO BE BOUND BY ITS RULES AND REGULATIONS AND ANY FUTURE MODIFICATION THEREOF. MEMBERSHIP DOES NOT GUARANTEE SEATS