Office: 868 Glen Huntly Road, Caulfield South

בס"ד

בית דין צדק דק"ק מעלבארן והמדינה

MELBOURNE BETH DIN

JEWISH RELIGIOUS COURT

Office: 868 Glen Huntly Road, Caulfield South

Postal address: PO Box 2407 Caulfield Junction, Victoria 3161

Telephone: (03) 9523 7748 Fax: (03) 9523 7709 Email:

Application for Admission to the Jewish Faith

CONFIDENTIAL

If completing on a computer, type in the grey boxes. Double-click on the check boxes to mark them checked or not.

Personal Particulars

Full Name:
Any Former Name (including Maiden Name) / Phone Numbers: / Home
Work
Mobile
Correspondence Address: / Email Address
Home Address (If different):
Date of Birth / Occupation
Name and address of Employer/ Business
Marital Status Single
MarriedDivorced Girl/Boyfriend Is your Current/Former Partner Jewish Gentile

If Married, Please enter DetailsOf the Marriage

Date of Marriage / Location of Marriage
Full Name of Spouse: / Jewish Name
Any Former Name (including Maiden Name) / Phone Numbers: / Home
Work
Mobile
Occupation / Email Address
Children of this marriage
Name / Male Female / Date of Birth
Name / Male Female / Date of Birth
Name / Male Female / Date of Birth

If Engaged or with a long-term partner, Please Complete this Section

Their Full Name: / Jewish Name
Any Former Name (including Maiden Name) / Phone Numbers: / Home
Work
Mobile
Occupation / Email Address
Name and address of Employer/ Business
Is your intended partner a / Cohen Levy Yisrael
If you have children with this person, please list
Name / Male Female / Date of Birth
Name / Male Female / Date of Birth
Name / Male Female / Date of Birth

If your intended Partner was previously married, please complete this section

Date of Marriage / Location of Marriage
Date and place of civil Divorce / Date and place of Gett (religious divorce)
Full Name of former Spouse: / Jewish Name
Partner’s children from that relationship
Name / Male Female / Date of Birth
Name / Male Female / Date of Birth
Name / Male Female / Date of Birth

If you were previously married, Please complete this section

Date of Marriage / Location of Marriage
Date and place of civil Divorce / Full Name of former Spouse:
Children from that relationship
Name / Male Female / Date of Birth
Name / Male Female / Date of Birth
Name / Male Female / Date of Birth
Please describe the living arrangements for these children

ALL APPLICANTS, Please complete this section

Have you ever been convicted of a crime? / Yes No / If Yes, please give details:
Have you ever undergone psychological counselling? / Yes No / If Yes, please give details:
The Melbourne Beth Din reserves the right to conduct a security check at our discretion. In completing and signing this form, you agree that the information given may be used in obtaining our security clearance.
Please give the name and address of an orthodox Rabbi (preferably your Rabbinic Mentor) who knows you and who can act as a character referee on your behalf:
Name: / Rabbi / Phone Numbers: / Home
Work
Mobile
Correspondence Address: / Email Address
DECLARATION: I affirm that the information I have supplied in this form is true and accurate, to the best of my knowledge. I hereby authorise the Melbourne Beth Din to make any enquiries it deems necessary for the purposes of my application and ongoing conversion process, including but not limited to checking references and security check.
Signed / Date