Membership Application Membership Application Step 1 of 6 16% Your Personal InformationDate of Application MM slash DD slash YYYY Choose One Mr. Mrs. Miss Ms. Dr. Hon. Person 1 First Last Hebrew NameDate of BirthChoose One Mr. Mrs. Miss Ms. Dr. Hon. Person 2 First Last Hebrew NameDate of BirthEmail Address 1 Enter Email Confirm Email Email Address 2 Enter Email Confirm Email Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Do you live in OTOW, Stone Creek or Calesa? If so, what neighborhood?Home PhoneCell PhoneMarital Status Married Single Widowed Divorced Couple Anniversary Person 1Profession/Occupation (former if retired) Sales Marketing Engineering IT/Technical Clerical/Accounting Facilities Maintenance Other Company/OrganizationAddress, Business PhonePerson 2Profession/Occupation (former if retired) Sales Marketing Engineering IT/Technical Clerical/Accounting Facilities Maintenance Other Company/OrganizationAddress, Business PhoneBilling AddressIn case of emergency, notifyName/Phone # Child 1:Name/Nickname Date of Birth Bar/Bat Mitzvah - Year/Where Confirmation - Year/Where Attending College? Any other info?Child 2Name/Nickname Date of Birth Bar/Bat Mitzvah - Year/Where Confirmation - Year/Where Attending College? Any other info?GrandchildrenName(s) Date(s) of birthParents, Person 1Name If deceased, date of deathParents, Person 2Name If deceased, date of deathReligious Tradition raised, Person 1ReformConservativeOrthodoxJew by ChoiceNon-JewReligious Tradition raised, Person 2ReformConservativeOrthodoxJew by ChoiceNon-JewPrevious Congregational AffiliationName and Location Affiliation Dates Active in Synagogue Life? Reason for Resignation? Date of ResignationFirst ChoiceSecond ChoiceThird Choice Yahrzeit 1English Name; Hebrew Name; To Whom: Member 1 or Member 2; English Date (required); Hebrew Date; Relationship;Yahrzeit 2English Name; Hebrew Name; To Whom: Member 1 or Member 2; English Date (required); Hebrew Date; Relationship;Yahrzeit 3English Name; Hebrew Name; To Whom: Member 1 or Member 2; English Date (required); Hebrew Date; Relationship;Yahrzeit 4English Name; Hebrew Name; To Whom: Member 1 or Member 2; English Date (required); Hebrew Date; Relationship;Yahrzeit 5English Name; Hebrew Name; To Whom: Member 1 or Member 2; English Date (required); Hebrew Date; Relationship;Yahrzeit 6English Name; Hebrew Name; To Whom: Member 1 or Member 2; English Date (required); Hebrew Date; Relationship;Yahrzeit 7English Name; Hebrew Name; To Whom: Member 1 or Member 2; English Date (required); Hebrew Date; Relationship;Yahrzeit 8English Name; Hebrew Name; To Whom: Member 1 or Member 2; English Date (required); Hebrew Date; Relationship; Getting to Know YouNew to Ocala?YesNoJewish Organizations You are involved with or Want to learn more about:Are you related to members of the Temple Beth Shalom family? If so, please list names/relationships:How did you learn about Temple Beth ShalomWebsiteFriend/Family MemberWord of MouthOtherHow can we help you grow in Judaism? Temple Beth Shalom offers ongoing classes for adults in the congregation on a variety of topics. What topics are you interested in studying? (for Example: B'nai Mitzvah training, learning to read/speak Hebrew, learning parts of the service, Torah study)May we call upon you for Hebrew service participation? Please indicate all you are comfortable with:Candle Lighting/BlessingKiddush/MotziArk OpeningTorah ChantingHaftarah ChantingEnglish ReadingSponsoring an OnegPublicityMay we share the joy of your birthday/anniversary with the Congregation in the Temple Bulletin and Sisterhood Uniongrams?Person 1YesNoMay we share the joy of your birthday/anniversary with the Congregation in the Temple Bulletin and Sisterhood Uniongrams?Person 2YesNoDo you give permission to have photographs taken and used in the Temple Bulletin or other communications?Person 1YesNoDo you give permission to have photographs taken and used in the Temple Bulletin or other communications?Person 2YesNo Membership Categories/Dues - Security Fee Per Membership Unit: $150; Capital Fund - to be discussed with Treasurer upon acceptance of membership(Required)Please Select 1 Category; Family Membership (2 or more adults with or without children under 21) $1500 Individual Family Membership (1 adult with children under 21) $1100 Single Membership (1 adult) $900 Associate Membership (1 or more adults residing outside Marion or any contiguous counties) $500 Candidate (including Conversion Students) Membership $500 If you are experiencing financial difficulties, please speak with our Treasurer and/or PresidentNO MEMBERSHIP WILL BE DENIED BECAUSE OF DUESAnything Else We Need to Know? 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