Membership Form Leave empty Application for MembershipPrivate & confidentialI apply to join Moor Lane and agree to abide by the rules and membership arrangements of the congregation.Applicant details Membership type soughtPlease selectFamilyYoung AdultCountryFull-time StudentHonoraryBusiness AccountGenderPlease selectMaleFemalePreferred nameTitlePlease selectMrMrsMissMsDrRabbiFirst nameLast nameHebrew nameCohen / Levi / IsraelPlease selectCohenLeviIsraelIsrael (Convert)Father's nameFather's Hebrew nameMother's nameMother's Hebrew nameDate of birthHebrew date of birthBorn during dayBorn after sunsetPlace and country of birthOccupation / skillsCurrent photo (applicant and partner if married)Marital statusPlease selectSingleMarriedCivil PartershipDivorcedWidowedPrefer not to sayLate husband's Hebrew name (if applicable)Contact and household Email addressMobile numberHome telephoneOffice telephoneFull addressPostcodePreferred contact methodPlease selectEmailMobileTelephonePostSynagogue information Previous synagogue name and addressIntroduced by / nearest relative who is a memberConversion information Conversion: authorising Beth Din and date (if applicable)Additional information For a single applicant: parents' synagogue and marriage datePartner and family Partner full namePartner Hebrew namePartner maiden namePartner date of birthPartner telephonePartner emailPartner occupationSynagogue, place and date of marriageCopy of KetubahChildren: English/Hebrew names and dates of birthSupport and consent Would you like pastoral contact?Please selectYesNoWilling to sign a Gift Aid form?Please selectWillingNot willingBurial contribution preferencePlease selectI wish to contributeI do not currently wish to acquire burial rightsAnything else we should knowDeclaration I confirm this information is accurate and consent to Moor Lane processing it for my membership application. Applicant signature (type your first and last name exactly as entered above) Date signed Submit application
