Sephardic Brotherhood Membership Application

Applicant's Full Name*

Date of Birth*

Date

Hebrew Name*

Mother's Hebrew Name*

Mother's Full (Maiden) Name*

Father's Full Name*

Membership Type Candidate is Applying for (Check Box):*

Full MembershipSocial MembershipReinstatement of BenefitsJunior Membership

Mother's Jewish Status:*

JewishNot Jewish

Father's Jewish Status:*

JewishNot Jewish

Is Your Mother Living?*

YesNo

Is your Father Living?*

YesNo

If deceased, please indicate full Hebrew name and date of Passing for their Annual Meldado (Memorial)

Home Address (Include Address, Apt/Suite, City, State, Zip*

Home phone

Cell phone*

Primary Email*

example@example.com

Current Job Title*

Employer/Place of Business*

Industry*

Spouse's Name (If no spouse, write N/A)

Spouse's Date of Birth

Date

Hebrew Name

Spouse's Mother's Hebrew Name

Spouse's Mother's Full (Maiden) Name

Spouse's Mother's Jewish Status:

JewishNot Jewish

Is Your Spouse's Mother Living?

YesNo

Spouse's Father's Full Name

Spouse's Father's Jewish Status:

JewishNot Jewish

Is your Spouse's Father Living?

YesNo

If deceased, please indicate full Hebrew name and date of Passing for their Annual Meldado (Memorial)

Spouse's Email Address

example@example.com

Spouse's Cell Phone

Spouse's Current Job Title

Spouse's Employer

Spouse's Industry

Have you (the applicant), your parents, or grandparents undergone conversion to Judaism:

YesNo

If yes, please indicate who in your family has undergone conversion, date of conversion, place, and Beth Din (Jewish Court) that conducted the Conversion

Has your spouse, their parents, or grandparents undergone conversion to Judaism:

YesNo

If yes, please indicate who in your spouse's family has undergone conversion, date of conversion, place, and Beth Din (Jewish Court) that conducted the Conversion

Children or Dependent(s) (Include Email if Age 16 or Older):

Name

DOB

Email

example@example.com

Name

DOB

Email

example@example.com

Name

DOB

Email

example@example.com

Name

DOB

Email

example@example.com

Do You or Your Spouse Have Any Relatives that are Members of the Sephardic Brotherhood? If Yes, Please List Their Name(s)

Are you currently affiliated with any synagogue or Jewish community organization? If Yes, please list your affiliations

Any Additional Notes on your background you would like the review committee to know, such as your family's Sephardic Origins

I, the undersigned, hereby certify that all the statements, representations and answers contained in this application and in every part thereof, are full, complete, and true. I agree that any untrue statement or misrepresentationof information on this application shall forfeit my rights and the rights of my dependents and beneficiaries under my membership. It is understood that my membership shall commence after my notification of approval from the Executive Committee of the organization, my payment of the relevant initiation fee and membership dues, and issuance of a membership file number. I understand that should be married to a non-Jewish spouse now or in the future, that spouse will not be entitled to any benefits under my membership and my current or future children will not be entitled to benefits of membership should their mother not be Jewish according to Jewish Law (halakha)

Signature (I agree that any electronic signatures appearing on this document or such other documents are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility).*

Date of Application*

Date