Previous Names (Eg Maiden Name):______

Personal Details

Applicant 1

Title: ______Surname: ______Forename(s):______

Previous names (eg Maiden name):______

Hebrew name: ______Mother’s Hebrew Name:______

Are you a: Cohen / Levi (Please circle one) Date of Birth: ( / / )

Gender: Male / Female (Please circle one)

Mobile number: ______Work number: ______

Email: ______

Spouse of Applicant 1 (if joining)

Title: ______Surname: ______Forename(s):______

Previous names (eg Maiden name):______

Hebrew name: ______Mother’s Hebrew Name:______

Are you a: Cohen / Levi (Please circle one) Date of Birth: (dd/mm/yyyy) / /

Gender: Male / Female (Please circle one)

Mobile number: ______Work number: ______

Email: ______

Contact details

Address Line 1: ______

Address Line 2: ______

Town: ______County: ______

Postcode: ______Home Tel: ______

If single:

Father’s forename: ______Father’s surname (If different): ______

Mother’s forename: ______Mother’s maiden name: ______

Date of parent’s marriage: (dd/mm/yyyy) / /

Full Name of Synagogue in which your parents were married:

______

Address of Synagogue (City and Country):

Are your parents currently members of a United Synagogue? Y/N

If yes, please state which one: ______

If Married: Date of marriage: (dd/mm/yyyy) / /

Full Name of Synagogue: ______

Address of Synagogue (City and Country):

Children’s Details

Please provide details of your children who are under 21

Child 1:

Forenames: ______

Surname: ______

Email: ______

Hebrew name: ______

Date of Birth(dd/mm/yyyy) : / /

Gender M/F (Please circle)

Child 2:

Forenames: ______

Surname: ______

Email: ______

Hebrew name: ______

Date of Birth(dd/mm/yyyy) : / /

Gender M/F (Please circle)

Child 3:

Forenames: ______

Surname: ______

Email: ______

Hebrew name: ______

Date of Birth(dd/mm/yyyy) : / /

Gender M/F (Please circle)

Please continue on a separate sheet if more children.

Yahrzeits

The Yahrzeit is the Hebrew anniversary of a relative’s death. We will be able to send you a yearly letter to state the English date it corresponds to.

Applicant 1

Forename of Deceased: ______Surname of Deceased: ______

Hebrew name: ______

Relationship to Member: ______

Date deceased (English or Hebrew, please include year): ______

Time of death:am/pm (please delete as applicable)

Forename of Deceased: ______Surname of Deceased: ______

Hebrew name: ______

Relationship to Member: ______

Date deceased (English or Hebrew, please include year): ______

Time of death:am/pm (please delete as applicable)

Forename of Deceased: ______Surname of Deceased: ______

Hebrew name: ______

Relationship to Member: ______

Date deceased (English or Hebrew, please include year): ______

Time of death:am/pm (please delete as applicable)

Applicant 2

Forename of Deceased: ______Surname of Deceased: ______

Hebrew name: ______

Relationship to Member: ______

Date deceased (English or Hebrew, please include year): ______

Time of death:am/pm (please delete as applicable)

Forename of Deceased: ______Surname of Deceased: ______

Hebrew name: ______

Relationship to Member: ______

Date deceased (English or Hebrew, please include year): ______

Time of death:am/pm (please delete as applicable)

Forename of Deceased: ______Surname of Deceased: ______

Hebrew name: ______

Relationship to Member: ______

Date deceased (English or Hebrew, please include year): ______

Time of death:am/pm (please delete as applicable)

Please continue on a blank page for both applicants if necessary

Terms and conditions

1. Membership is available only to persons of the Jewish Religion as defined by the Court of the Chief Rabbi.

2. Membership of the Synagogue entitles you to become a member of the SWHC Burial Society for a small additional annual cost. Payment into the scheme must be continuous and for people joining over the age of 40 there is an entrance fee depending on age. Please tick the box if you wish to join our Burial Society ( )

(We will advise you of the overage joining fee. If you are joining as a married couple this is based on husband’s age). Children under 21 in full time education are covered by family membership’

(Children over 21 will need to take membership in their own right.)

3. Seating can also be rented at a small additional annual cost. Please indicate if you would like a named seat in Shul. Gentlemen’s seat ( ) Ladies Seat ( )

4. There are also a small number of ladies lockers that may be rented annually. Please indicate if you wish to be allocated a locker. Ladies locker ( )

Signature 1: ______Signature 2: ______

Date (dd/mm/yyyy): / /

For office use:-

Ketuba Seen
Membership Fee Percentage
Burial Required
Seat Fee
Locker Fee
Date / Signature
Interviewed by
Approved by Treasurer
Approved by Rabbi
Approved by Council

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