Kehillat Chovevei Tzion
PO Box 544
East Setauket, NY 11733
631-476-3623
http://www.kct.org

MEMBERSHIP APPLICATION

FAMILY NAME: ____________________________________________

FIRST NAME(S) (adults):

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(English)                            (Hebrew Name)                                        (if male, Cohen of Levi?)

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(English)                            (Hebrew Name)                                        (if male, Cohen of Levi?)

Other adults living in home:

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(English)                            (Hebrew Name)                                        (if male, Cohen of Levi?)

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(English)                            (Hebrew Name)                                        (if male, Cohen of Levi?)

Children:

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(English)                            (Hebrew Name)                          (Age)      (if male, Cohen of Levi?)

____________________________________________________________________________
(English)                            (Hebrew Name)                          (Age)      (if male, Cohen of Levi?)

____________________________________________________________________________
(English)                            (Hebrew Name)                          (Age)      (if male, Cohen of Levi?)

____________________________________________________________________________
(English)                            (Hebrew Name)                          (Age)      (if male, Cohen of Levi?)

ADDRESS: ___________________________________________________________________
  
___________________________________________________________________

Telephone:

Email:

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Fax:

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When you are ready, please attach your deposit check to this completed form and mail to KCT at the above address. We look forward to many years together.