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BS”D

CEDAR ROAD SYNAGOGUE

MEMBERSHIP APPLICATION

MEMBER #1 FULL NAME: __________________________________________________

Marital Status:  Please Circle:      Single         Married          Divorced          Widow/er

Aliyah Status:    Please Circle:           KOHEN          LEVI            YISROEL

Date of Birth: ____________Address: ____________________________________________

Suite #: _________City: ________________________ State: _______Zip Code: __________

Phone: (Home)__________________________ (Work) ______________________________

(Email): ___________________________________ (Cell Phone): ______________________

______________________________Bat/Ben_______________________________________

    Your Hebrew name     Bat(Daughter of)/Ben (Son of)      Father’s Hebrew name; Mother’s Hebrew name

ie       Chaim Dovid                               Ben            Reuven Ben Yaacov; Rifka bat Sarah

MEMBER #2 FULL NAME: __________________________________________________
Marital Status:   Please Circle:       Single         Married           Divorced            Widow/er

Date of Birth: ____________Address: ____________________________________________

Please Check if all Address Information is the Same as Above

Suite #:_______City: ___________________________ State: _______Zip Code: _________

Phone: (Home)____________________________ (Work) ____________________________

(Email): _____________________________________ (Cell Phone): ____________________

Hebrew Name: _______________________________Bat/Ben__________________________________

    Your Hebrew name         Bat(Daughter of)/Ben (Son of)          Father’s Hebrew name; Mother’s Hebrew Name

ie       Chana Rivka                               Bat               Reuven Ben Yaacov; Rifka bat Sarah

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