Membership Application

Membership Application
Membership (Dues include High Holiday Seats)

Family $850 Individual $550
Name *

First Name Last Name
Hebrew Name
Spouse Name

First Name Last Name
Spouse Hebrew Name
Child Name(s) - (Select "+" for additional lines) *
Parent's Hebrew Name: Father

First Name Last Name
Mother

First Name Last Name
Spouse's Parent's Hebrew Name: Father

First Name Last Name
Mother

First Name Last Name
Primary Residence

Street Address

Street Address Line 2

City State

Zip Code
Email *
example@example.com
Primary Phone *

Area Code Phone Number
Local Address

Street Address

Street Address Line 2

City State

Zip Code
Local Phone

Area Code Phone Number
Affiliation:

Kohan Levi Yisrael
Yahrzeit Record (select "+" for additional lines)
Select Activities of Interest

Adult Education Lectures Social Events Serve on Committees
List any skills or talents you have
Questions / Comments
Calculation
Payment Type:

Pay Online Now Mail in check
Please print (Ctrl P) to print this form and mail it to:

Congregation Tifereth Israel
Attention: Elaine Goldman
PO Box 659
Greenport, NY 11944

Check payable to: Congregation Tifereth Israel

Membership Dues

USD Description

Please contact Phil Goldman for any other questions.

(631) 765-3504

epgoldy@optonline.net
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