Membership Personal Information Form

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Please fill out every box unless it is not applicable. This will allow us to have all your accurate and current information on file.
FAMILY INFO
Family Name

Address

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

Home Phone

Area Code Phone Number
Husband's Cell Phone

Area Code Phone Number
Wife's Cell Phone

Area Code Phone Number
E-mail
HUSBAND INFO
First Name
Cohen/Levi/Yisroel Select one

CohenLeviYisroel
Date of Birth

Month Day Year
Hebrew Name
Father's Hebrew Name
Mother's Hebrew Name
Date of Marriage

Month Day Year
Location of Marriage
WIFE INFO
First Name
Date of Birth

Month Day Year
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

Month Day Year
Schools Attended
_____________________________________________________________________________________________________________________________________________________
Child 2 First Name
Child 2 Hebrew Name
Child 2 Date of Birth

Month Day Year
Schools Attended
_____________________________________________________________________________________________________________________________________________________
Child 3 First Name
Child 3 Hebrew Name
Child 3 Date of Birth

Month Day Year
Schools Attended
_____________________________________________________________________________________________________________________________________________________
Child 4 First Name
Child 4 Hebrew Name
Child 4 Date of Birth

Month Day Year
Schools Attended
YARTZEIT HUSBAND'S FAMILY
Full Hebrew Name
Full English Name
Relationship
Date of Passing

Month Day Year
Time of Passing
Hour Minutes
_____________________________________________________________________________________________________________________________________________________
Full Hebrew Name
Full English Name
Relationship
Date of Passing

Month Day Year
Time of Passing
Hour Minutes
YARTZEIT WIFE'S FAMILY
Full Hebrew Name
Full English Name
Relationship
Date of Passing

Month Day Year
Time of Passing
Hour Minutes
_____________________________________________________________________________________________________________________________________________________
Full Hebrew Name
Full English Name
Relationship
Date of Passing

Month Day Year
Time of Passing
Hour Minutes
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

Month Day Year
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