New Affiliate Member Application

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Primary Account Holder Information

* Primary Person Title

* Primary Person First Name

* Primary Person Last Name

* Home Telephone

* Best Email Address

* Cell Phone Number

* Date of Birth

* Hebrew First Name

* Father's Hebrew Name

* Mother's Hebrew Name

* Were You Born Jewish?

Please Select OneYesNo (Please provide details of conversion)

* Please provide details of conversion

* Occupation

Business Name

* Marital Status

Date of Marriage

Secondary Account Holder Information

Spouse's First Name

Spouse's Last Name

Cell Phone Number:

Email Address:

Date of Birth:

Hebrew Name:

Father's Hebrew Name

Mother's Hebrew Name

Were You Born Jewish?

Please Select OneYesNo (Please provide details of conversion)

* Please provide details of conversion

Occupation

Business Name

Account Information

* Home Street Address

* City

* State

* Zip Code

Please list the English & Hebrew Names of Any Unmarried Children, Dates of Birth & Gender

Please list the English & Hebrew Names of Any Married Children & their Spouses Names

Please List All Yahrzeits:

Please include for each deceased individual:
English Name
Hebrew Name (ex. Yitzchak ben Avraham)
Secular & Hebrew Date & Year of Death
Your Relationship to the deceased

* Shul Affiliation- At Which You Are Currently a Full Member in Good Standing; List Name, Location & Phone Number

(You may list more than one.)

* We/I apply for affiliate membership in Congregation Bnai Yeshurun ($400) and accept the financial obligations as set by the synagogue and agree to abide by the Constitution and By-laws.

We/I apply for affiliate membership in Congregation Bnai Yeshurun ($400) and accept the financial obligations as set by the synagogue and agree to abide by the Constitution and By-laws.

Wed, September 17 2025 24 Elul 5785

641 West Englewood Avenue

Teaneck, NJ 07666

201.836.8916

office@bnaiyeshurun.org

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