Membership Personal Information Form

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FAMILY INFO
Family Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone
Area CodePhone Number
Husband's Cell Phone
Area CodePhone Number
Wife's Cell Phone
Area CodePhone Number
E-mail
HUSBAND INFO
First Name
Cohen/Levi/YisroelSelect one
CohenLeviYisroel
Date of Birth
MonthDayYear
Hebrew Name
Father's Hebrew Name
Mother's Hebrew Name
Date of Marriage
MonthDayYear
Location of Marriage
WIFE INFO
First Name
Date of Birth
MonthDayYear
Hebrew Name
Father's Hebrew Name
Mother's Hebrew Name
CHILDREN INFO
Child 1 First Name
Child 1 Hebrew Name
Child 1 Date of Birth
MonthDayYear
Schools Attended
_____________________________________________________________________________________________________________________________________________________
Child 2 First Name
Child 2 Hebrew Name
Child 2 Date of Birth
MonthDayYear
Schools Attended
_____________________________________________________________________________________________________________________________________________________
Child 3 First Name
Child 3 Hebrew Name
Child 3 Date of Birth
MonthDayYear
Schools Attended
_____________________________________________________________________________________________________________________________________________________
Child 4 First Name
Child 4 Hebrew Name
Child 4 Date of Birth
MonthDayYear
Schools Attended
YARTZEIT HUSBAND'S FAMILY
Full Hebrew Name
Full English Name
Relationship
Date of Passing
MonthDayYear
Time of Passing
HourMinutes
_____________________________________________________________________________________________________________________________________________________
Full Hebrew Name
Full English Name
Relationship
Date of Passing
MonthDayYear
Time of Passing
HourMinutes
YARTZEIT WIFE'S FAMILY
Full Hebrew Name
Full English Name
Relationship
Date of Passing
MonthDayYear
Time of Passing
HourMinutes
_____________________________________________________________________________________________________________________________________________________
Full Hebrew Name
Full English Name
Relationship
Date of Passing
MonthDayYear
Time of Passing
HourMinutes
I hereby certify that all information given above is true and correct and that I, and all members of my immediate family named herein, are Jewish by birth, or by conversion in accordance with Orthodox Halachik Standards.
I have read and accepted the by-laws of Chabad Lubavitch of Markham.
Yes
Signature
Date
MonthDayYear
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Membership Personal Information Form

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