Enrollment Questionnaire | Membership Form | United Hebrew Company of New York

Enrollment Questionnaire

Please complete the form below ONLY after receiving a quote from our office.

For more information, please visit Membership Plans

UHC Questionnaire

THIS IS A NO OBLIGATION QUESTIONNAIRE FOR MEMBERSHIP ENROLLMENT

I hereby request an applicant's agreement from the

UNITED HEBREW COMMUNITY OF NEW YORK ADATH ISRAEL OF NEW YORK
for a (CHOOSE ONE)

REGULAR / FAMILY MEMBER

LIFE MEMBER

SPECIAL MEMBER

RESERVED GRAVE

ALL INFORMATION IS CONFIDENTIAL

MOST INFORMATION IS REQUIRED ON A DEATH CERTIFICATE OR BY THE OFFICIATING RABBI

PLEASE ENTER ALL INFORMATION AND ANSWER ALL APPLICABLE QUESTIONS

APPLICANT(Required)
(First Name) (Middle Name) If none type NMN (Last Name)
IF THE MAILING ADDRESS IS DIFFERENT, SEE THE BOTTOM OF THIS FORM

ADDRESS(Required)
Street Address City State / Province / Region ZIP / Postal Code

HOME PHONE

CELL PHONE

EMAIL(Required)

SOCIAL SECURITY #(Required)

DATE OF BIRTH(Required)
MM slash DD slash YYYY

BIRTH PLACE (County/City/State/Country)(Required)

APPLlCANT'S JEWlSH NAME (ln Hebrew or Phonetically in English)(Required)

IF UNKNOWN USE ENGLISH NAME

APPLICANT'S FATHER'S COMPLETE ENGLISH NAME(Required)

FATHER'S JEWISH NAME (ln Hebrew or Phonetically in English)(Required)

IF UNKNOWN USE ENGLISH NAME

APPLICANT'S MOTHER'S ENGLISH AND MAIDEN NAME(Required)

IF HER MAIDEN NAME IS UNKNOWN TYPE "UNKNOWN"

MOTHER'S JEWISH NAME (ln Hebrew or Phonetically in English)(Required)

IF UNKNOWN USE ENGLISH NAME

*Please email any document to verify the spelling of the Hebrew names to [email protected]

APPLICANT'S OCCUPATION (Prior to Retirement)(Required)

INDUSTRY OF OCCUPATION(Required)

HIGHEST GRADE OF EDUCATION COMPLETED OR DEGREE(Required)

MARITAL STATUS(Required)

ARE YOU MARRIED ACCORDING TO JEWISH LAW?(Required)
If yes, please email a copy of your Ketubah (Jewish Marriage Certificate) to [email protected]

DATE OF MARRIAGE
MM slash DD slash YYYY

NAME OF OFFICIATING RABBI

WIFE'S NAME (if applicable)

NOTE: IF YOU ARE NOT MARRIED, KINDLY TYPE N/A IN ALL "REQUIRED" FIELDS FOR SPOUSE

SOCIAL SECURITY #

DATE OF BIRTH(Required)
MM slash DD slash YYYY

IF YOU ARE NOT MARRIED, KINDLY USE TODAYS DATE

BIRTH PLACE (County/City/State/Country)(Required)

WIFE'S CELL PHONE

EMAIL

WIFE'S JEWISH NAME (ln Hebrew or Phonetically in English)(Required)

IF UNKNOWN USE ENGLISH NAME

WIFE'S FATHER'S COMPLETE ENGLISH NAME(Required)

WIFE'S FATHER'S JEWISH NAME (ln Hebrew or Phonetically in English)(Required)

IF UNKNOWN USE ENGLISH NAME

WIFE'S MOTHER'S ENGLISH AND MAIDEN NAME(Required)

IF HER MAIDEN NAME IS UNKNOWN TYPE "UNKNOWN"

WIFE'S MOTHER'S JEWISH NAME (ln Hebrew or Phonetically in English)(Required)

IF UNKNOWN USE ENGLISH NAME

*Please email any document to verify the spelling of the Hebrew names to [email protected]

WIFE'S OCCUPATION (Prior to Retirement)(Required)

INDUSTRY OF OCCUPATION(Required)

HIGHEST GRADE OF EDUCATION COMPLETED OR DEGREE(Required)

ARE YOU A VETERAN OF THE U.S. ARMED FORCES?(Required)

IF YES, NUMBER OF YEARS SERVED:

ARE YOU A MEMBER OF OR DO YOU REGUARLY ATTEND A SYNAGOGUE?(Required)

IF YES, NAME & ADDRESS

NAME OF RABBI

ARE YOU OR YOUR SPOUSE A CONVERT TO THE JEWSH FAITH?(Required)

IF YES, PLEASE EMAIL A COPY OF THE CONVERSION CERTIFICATE AND DOCUMENTS TO [email protected] (Required)

ARE YOU OR YOUR SPOUSE (OR ANY CHILD, WHO IS TO BE INCLUDED IN THE MEMBERSHIP) DISABLED OR CHRONICALLY ILL?(Required)

IF YES, NAME(S)

NAME OF THE FACILITY

ARE YOU OR YOUR SPOUSE (OR ANY CHILD, WHO IS TO BE INCLUDED IN THE MEMBERSHIP) IN A HOSPITAL OR ANY OTHER INSTITUTION?(Required)

lF YES, NAME(S)

DID YOU OR ANY MEMBER OF YOUR FAMILY EVER BELONG TO OUR ORGANIZATION?(Required)

IF YES, NAME(S) OF THE MEMBER(S)

ARE THERE CURRENTLY SPECIFIC GRAVE(S) RESERVED IN YOUR NAME(S)?(Required)

IF YES, PROVIDE THE CEMETERY NAME

GRAVE LOCATION

BLOCK

SECTION

ROW

GRAVE NUMBER(S)

(P)LOT

OTHER GRAVE OR PLOT INFORMATION

SOCIETY NAME (if applicable)

DO YOU HAVE A DEED, RECEIPT, PERMIT, LETTER, CANCELED CHECK(S) FOR RESERVED GRAVE(S)?
If yes, please email a copy of the documents to [email protected].

TO BE COMPLETED BY APPLICANTS FOR REGULAR / FAMILY MEMBERSHIP ONLY

SONS UNDER 18 YEARS OF AGE

Name

DOB
MM slash DD slash YYYY

Name

DOB
MM slash DD slash YYYY

Name

DOB
MM slash DD slash YYYY

DAUGHTERS WHO HAVE NEVER BEEN MARRIED

Name

DOB
MM slash DD slash YYYY

Name

DOB
MM slash DD slash YYYY

Name

DOB
MM slash DD slash YYYY

INDIVIDUALS TO BE INFORMED IN CASE OF EMERGENCY... NEXT OF KIN

NAME(Required)

RELATIONSHIP(Required)

ADDRESS(Required)
Street Address City State / Province / Region ZIP / Postal Code

HOME PHONE(Required)

CELL PHONE(Required)

NAME

RELATIONSHIP

ADDRESS
Street Address City State / Province / Region ZIP / Postal Code

HOME PHONE

CELL PHONE

ENROLLMENT PAYMENT SCHEDULE

PLEASE BILL ME AS FOLLOWS: (CHOOSE ONE)

1) PAYMENT IN FULL

2) NO INTEREST INSTALLMENT PLAN:

YOU WILL BE BILLED WHEN OUR CONTRACT AND ADDITIONAL PAPERWORK ARE SENT FOR YOUR SIGNATURE

IF PAYMENT(S) ARE TO BE MADE BY A PERSON OTHER THAN THE APPLICANT

NAME

RELATIONSHIP TO APPLICANT

ADDRESS
Street Address APT City State / Province / Region ZIP / Postal Code Country

BEST TELEPHONE NUMBER DURING BUSINESS HOURS

MAILING ADDRESS, IF DIFFERENT THAN PHYSICAL ADDRESS:
STREET APT City State / Province / Region ZIP / Postal Code Country

PLEASE ADVISE US BELOW OF ANY SPECIAL NEEDS OR OTHER INFORMATION THAT YOU THINK MAY BE IMPORTANT TO YOUR MEMBERSHIP

I Hereby Affirm That The Information Provided In This Questionnaire Is Accurate And Correct(Required)
First Last

CAPTCHA

Post Custom Field

United Hebrew Community of New York

United Hebrew Community

of New York

UHC Questionnaire

THIS IS A NO OBLIGATION QUESTIONNAIRE FOR MEMBERSHIP ENROLLMENT

I hereby request an applicant's agreement from the

UNITED HEBREW COMMUNITY OF NEW YORK ADATH ISRAEL OF NEW YORK
for a (CHOOSE ONE)

UNITED HEBREW COMMUNITY OF NEW YORK ADATH ISRAEL OF NEW YORK

ALL INFORMATION IS CONFIDENTIAL

MOST INFORMATION IS REQUIRED ON A DEATH CERTIFICATE OR BY THE OFFICIATING RABBI

PLEASE ENTER ALL INFORMATION AND ANSWER ALL APPLICABLE QUESTIONS

GRAVE LOCATION

TO BE COMPLETED BY APPLICANTS FOR REGULAR / FAMILY MEMBERSHIP ONLY

SONS UNDER 18 YEARS OF AGE

DAUGHTERS WHO HAVE NEVER BEEN MARRIED

INDIVIDUALS TO BE INFORMED IN CASE OF EMERGENCY... NEXT OF KIN

ENROLLMENT PAYMENT SCHEDULE

PLEASE BILL ME AS FOLLOWS: (CHOOSE ONE)

YOU WILL BE BILLED WHEN OUR CONTRACT AND ADDITIONAL PAPERWORK ARE SENT FOR YOUR SIGNATURE

IF PAYMENT(S) ARE TO BE MADE BY A PERSON OTHER THAN THE APPLICANT

United Hebrew Community of New York

United Hebrew Community

of New York

UHC Questionnaire

THIS IS A NO OBLIGATION QUESTIONNAIRE FOR MEMBERSHIP ENROLLMENT

I hereby request an applicant's agreement from the

UNITED HEBREW COMMUNITY OF NEW YORK ADATH ISRAEL OF NEW YORK for a (CHOOSE ONE)

UNITED HEBREW COMMUNITY OF NEW YORK ADATH ISRAEL OF NEW YORK

ALL INFORMATION IS CONFIDENTIAL

MOST INFORMATION IS REQUIRED ON A DEATH CERTIFICATE OR BY THE OFFICIATING RABBI

PLEASE ENTER ALL INFORMATION AND ANSWER ALL APPLICABLE QUESTIONS

GRAVE LOCATION

TO BE COMPLETED BY APPLICANTS FOR REGULAR / FAMILY MEMBERSHIP ONLY

SONS UNDER 18 YEARS OF AGE

DAUGHTERS WHO HAVE NEVER BEEN MARRIED

INDIVIDUALS TO BE INFORMED IN CASE OF EMERGENCY... NEXT OF KIN

ENROLLMENT PAYMENT SCHEDULE

PLEASE BILL ME AS FOLLOWS: (CHOOSE ONE)

YOU WILL BE BILLED WHEN OUR CONTRACT AND ADDITIONAL PAPERWORK ARE SENT FOR YOUR SIGNATURE

IF PAYMENT(S) ARE TO BE MADE BY A PERSON OTHER THAN THE APPLICANT

UNITED HEBREW COMMUNITY OF NEW YORK ADATH ISRAEL OF NEW YORK
for a (CHOOSE ONE)