FAMILY INFO Family Name Address City, Postal Code Home phone Business phone Email HUSBAND INFO WIFE INFO First Name First Name Cohen Levi Yisroel Hebrew Name Hebrew Name Date of Birth / / Month Day Year Date of Birth / / Month Day Year Father's Hebrew Name Father's Hebrew Name Mother's Hebrew Name Mother's Hebrew Name Date of Marriage / / Month Day Year Location of Marriage CHILDREN INFO First Name Hebrew Name Date of Birth Schools Attended / / Month Day Year / / Month Day Year / / Month Day Year / / Month Day Year YARTZEIT HUSBAND'S FAMILY Full Hebrew Name Full English Name Relationship Date of passing Time of passing / / MM DD YY 12:00 12:30 1:00 1:30 2:00 2:30 3:00 3:30 4:00 4:30 5:00 5:30 6:00 6:30 7:00 7:30 8:00 8:30 9:00 9:30 10:00 10:30 11:00 11:30 Time AM PM / / MM DD YY 12:00 12:30 1:00 1:30 2:00 2:30 3:00 3:30 4:00 4:30 5:00 5:30 6:00 6:30 7:00 7:30 8:00 8:30 9:00 9:30 10:00 10:30 11:00 11:30 Time AM PM YARTZEIT WIFE'S FAMILY Full Hebrew Name Full English Name Relationship Date of passing Time of passing / / MM DD YY 12:00 12:30 1:00 1:30 2:00 2:30 3:00 3:30 4:00 4:30 5:00 5:30 6:00 6:30 7:00 7:30 8:00 8:30 9:00 9:30 10:00 10:30 11:00 11:30 Time AM PM / / MM DD YY 12:00 12:30 1:00 1:30 2:00 2:30 3:00 3:30 4:00 4:30 5:00 5:30 6:00 6:30 7:00 7:30 8:00 8:30 9:00 9:30 10:00 10:30 11:00 11:30 Time AM PM MEMBERSHIP CONTRIBUTIONS Please select appropriate category Type of Membership Family Single Standard Membership $2,360 $1,395 Senior Membership (age 70 and older) $1,415 $835 New Membership (1st year only) $1,600 $930 New Senior Membership (1st year only) $1,050 $610 NEW! Age 25-30 $400 $200 Age 31 $475 $290 Age 32 $625 $380 Age 33 $950 $575 Age 34 $1,425 $865 Building Fund (Mandatory) Please select appropriate category in accordance with the membership option selected above. (Children of Seat Foundation Members and those who have paid a Building Fund in another shul are exempt from this Building Fund.) Standard Members $1,800 $900 Senior Members (age 70 and older) $1,000 $500 Age 25-30 $300 $150 Age 31 $300 $150 Age 32 $400 $200 Age 33 $400 $200 Age 34 $400 $200 PAYMENT OPTIONS Card Type: Visa MC Name on Card: Card No: Exp: / 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. Signature Date / / Month Day Year *Subject to approval by the Committee This page uses 128 bit SSL encryption to keep your data secure.