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)

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)
IF THE MAILING ADDRESS IS DIFFERENT, SEE THE BOTTOM OF THIS FORM
ADDRESS(Required)
MM slash DD slash YYYY
IF UNKNOWN USE ENGLISH NAME
IF UNKNOWN USE ENGLISH NAME
IF HER MAIDEN NAME IS UNKNOWN TYPE "UNKNOWN"
IF UNKNOWN USE ENGLISH NAME
*Please email any document to verify the spelling of the Hebrew names to [email protected]
If yes, please email a copy of your Ketubah (Jewish Marriage Certificate) to [email protected]
MM slash DD slash YYYY
MM slash DD slash YYYY
IF YOU ARE NOT MARRIED, KINDLY USE TODAYS DATE
IF UNKNOWN USE ENGLISH NAME
IF UNKNOWN USE ENGLISH NAME
IF HER MAIDEN NAME IS UNKNOWN TYPE "UNKNOWN"
IF UNKNOWN USE ENGLISH NAME
*Please email any document to verify the spelling of the Hebrew names to [email protected]
IF YES, PLEASE EMAIL A COPY OF THE CONVERSION CERTIFICATE AND DOCUMENTS TO [email protected] (Required)

GRAVE LOCATION

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

MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY

DAUGHTERS WHO HAVE NEVER BEEN MARRIED

MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY

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

ADDRESS(Required)
ADDRESS

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

ADDRESS
MAILING ADDRESS, IF DIFFERENT THAN PHYSICAL ADDRESS:
I Hereby Affirm That The Information Provided In This Questionnaire Is Accurate And Correct(Required)