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MEMBERSHIP APPLICATION FORMReturn form by email to officemanager@ or by mail with check enclosed to: Congregation Anshei Shalom P.O. Box 410 West Hempstead, NY 11552Membership dues: New West Hempstead residents dues: $360 (Family) or $180 (Single) for first yearRegular Membership dues: $1300* (Family) or $650** (Single) * $1250 (FAMILY) or ** $625 (SINGLE) if paid in full by December 31stSisterhood dues are an additional $18.00 annually.Payment can be made online at pay or mailed to Anshei Shalom at the address listed above.Building Fund: $2,500 - can be paid in full upon joining or paid at the rate of $500 per year for five years.Security Assessment - $175.00 per yearDate: ____ /____ /______Family Name: ________________________Adult(s): 1) _____________ Mr. Mrs. Dr. 2) ____________ Mr. Mrs. Dr.Address: _______________________________________ Tribe:____ Kohen______ Levi_____Yisroel365760047625Telephone: Home (____) _____-_______ Do not register me for the WH Jewish Community Emergency & Shiva calls Cell 1) (____) _____-_______ Cell 2) (____) _____-_______ E-mail: 1) _______________________ 2) _______________________Name & location of previous Rabbi: ____________________________List all family members’ names (English & Hebrew) and birthdates (list additional on back): English Name Hebrew Name Birthdate (Include Father’s Name) ___________________________________ /___ /______ ___________________________________ /___ /______ ___________________________________ /___ /______ ___________________________________ /___ /_________________________________________ /___ /______MEMBERSHIP APPLICATIONOPTIONAL SECTIONWedding Anniversary Date: ___ /___ /______Yahrzeits (if any) (please list additional on the back): English English Name (First & Last) Hebrew Name Relationship Yahrzeit Date _______________ _________________ ________ ___ /___ /____________________ _________________ ________ ___ /___ /____________________ _________________ ________ ___ /___ /_____Are you interested in joining our Sephardic Minyan? (Y/N)Please check all groups, volunteer committees or activities that interest you:42640252222500277177531750174434519050 Sisterhood Brotherhood Chessed Committee Youth Committee 76009519050 Men’s Book Club Welcoming Committee Dinner Committee205930519050375856519050762000190507874006350395287534925 CSS Kiddush Committee Adult Education Events Committee 123063019050270510023813What, if any, portions of the davening service would you be willing to lead? Would you be willing to read Torah or Haftorah for the Shul? Any specific Parsha?Anything else you’d like us to know about you or your family members? Interests? Talents? Occupation? ................
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