Membership Information
Contact Information
Payment Information
Membership Information
Payment Type
No.
Membership Amount
Total
Replacement Card
26.00
Keilim
26.00
Bedika Cloths
5.00
Womens Member ($5 each visit)
130.00
Womens Sponsor ($3 each visit)
259.00
Womens Visit Non-Member
21.00
Womens Visit Off Hour
30.00
Womens Visit Member
5.50
Womens Visit Sponsor
3.50
Mens Weekly Membership
185.00
Mens Sheini-Chamishi Membership Twice weekly; Vis
259.00
Mens Daily Membership Or more than twice weekly
373.00
Mens One Week Membership
26.00
Mens One Month Membership
52.00
Mens Visit
5.50
Total
Please enter all attendee names
#
Payment Type
Guest First Name
Guest Last Name
Note (Exist. Members, enter card number)
Contact Information
Title
Title
Mr.
Mrs.
Rabbi
Dr. (Male)
Dr. (Female)
Ms.
Miss
*
First Name
*
Last Name
*
Address
*
City
*
State
*
Zip
*
Email
*
Phone
*
Payment Information
Additional Donation
Donation Amount
Grand Total Amount
*
Card Number
*
Card Expiration
Month
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
*
Year
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
*
Same as contact info
Billing Address
*
Zip Code
*
Name on Card
*
Security Code
*
Submit
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