PERSONAL INFORMATIONFull Name*First NameLast NameE-mail*Cell Number*Area CodePhone NumberI would like to receive news and updates by emailMEMBERSHIP PERKS* Seats for Rosh Hashanah and Yom Kippur* Super Member price for Shabbos Children's Programs * Special Member pricing for Shul programs and events* Discounted rate on Shul space rental for your Simcha. Subject to availability.* Discounted Men's Mikvah Entry Membership Plans - Please choose your membership option:$500 Single Membership - Includes 1 seat for Yom Tov$750 Senior Membership (65+) - Includes 2 seats for Yom Tov$950 Family Membership - Includes 2 seats for Yom Tov$750 First Year Family Membership - Includes 2 seats for Yom Tov$1,800 Chai Membership - Includes 4 seats for Yom Tov$10,000 Founding Membership - Includes 4 seats for Yom Tov & a plaque on the wall in the LobbySeats for Rosh Hashanah and Yom Kippur must be ordered in advanceMembers:Please reserve for me:Men's Seats that come with my Membership:1234Women's Seats that come with my Membership:1234Additional seats for Men-Members:$100 per seat12345Additional seats for Women-Members:$100 per seat12345Seats for Boys under Bar Mitzvah-Members:$36 per seat12345Seats for Girls under Bas Mitzvah-Members:$36 per seat12345Non-Members:Please reserve for me:Non-Member seats for Men:$250 per seat12345Non-Member seats for Women:$250 per seat12345Non-Member seats for Boys under Bar Mitzvah$72 for members12345Non-Members seats for Girls under Bas Mitzvah$72 for members12345Please note any seating requests here. We will do our best to accommodate you.ADDITIONAL CONTRIBUTIONSChai for Life - OptionalA contribution of “chai” ($18) or multiples of “chai” per month is a great way to ensure a percentage of your ma'aser goes back to your community, to keep YOUR community thriving. The contribution listed will be charged to your credit card monthly. Your name will be displayed with other Chai Club members.$18$36$54$72$90$108$126$144Building Facility Maintenance and Mortgage Debt - Optional$1000Total$0.00Yes, I'd like to donate the cost of processing this transaction by adding 3%Authorized amount to be chargedFull AmountQuarterly10 MonthsAny specific instructions please include here:PaymentCredit CardVisaMasterCardAmerican ExpressDiscoverCredit Card TypeCredit Card NumberSecurity CodeName on Card1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberExpiration Month2020202120222023202420252026202720282029Expiration YearBilling AddressStreet AddressStreet Address Line 2CityState / ProvincePostal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOtherCountrySubmitShould be Empty: This page uses TLS encryption to keep your data secure.