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		 AM 
PM

 /  /
 MM        DD            YY
 		 AM 
PM
YARTZEIT WIFE'S FAMILY
Full Hebrew Name  Full English Name Relationship Date of passing Time of passing

 /  /
 MM        DD           YY		 AM 
PM

 
 /  /
  MM        DD           YY

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