2018-19 Membership ApplicationName: First Last Hebrew Name Date of Birth E-mail:Cell Phone: Area Code - Phone Number Reg Phone: Area Code - Phone Number Business or Profession Company Name Company Phone: Area Code - Phone Number Name2: First Last Date of Birth 2 E-mail2:Cell Phone2: Area Code - Phone Number Business of Profession Business Name2 Business Phone2 Wedding Date:Children Names & Dates of BirthAddress: Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabweCountryYahrzeit RemindersEnglish Name Hebrew_Name Relationship Death DateName2 Relatinship2 Death Date2Hebrew Name2 Checkbox:Family Membership $1,190Single Membership $595Enter Dues $ Building Fund $ Total:Your info is submitted to the office when you hit submit. You will be taken to our secure payment processing page to pay online with Visa, MasterCard, Discover, American Express or your PayPal account. If you do not want to pay online, you can call the office at 516-466-0569 to pay by phone. We are happy to receive your check in the mail as well.THANK YOU!Yahrzeit(Please list name,relationships and dates)Lake Success Jewish Center2018-2019 Membership Application/DuesSubmitResetWhen you hit submit you will be taken to our payment page. Please indicate "Membership Dues" in the memo area when making the payment. If you do not want to pay online, and just want send in the form and mail in a check, you can just click "submit" and you are done. Thank you!
