2020-21 Membership FormName: First Last Date of Birth Name2: First Last Date of Birth 2 Children Names & Dates of BirthAddress: Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabweCountryPhone: Area Code - Phone Number E-mail:Family Membership includes 2 High Holiday seatsEnterUnder Age 35 $1000Age 35-64 $1,500Age 65 and Over $750Single Membership Includes 1 High Holiday seatEnter2Under Age 65 $750Age 65 and Over $500Associate Membership (a family or individual who has an existing membership at another shul may purchase holiday tickets at $86)Enter3Family $500Single $325Please specify your requirements for High Holiday Seats for this year:Number of Men Seats Required Number of Women's seats required: Please call me at the following number to discuss my seating needs Additional High Holiday seats may be purchased at the following rate:Members $86Non-Members $136You can go to the donation payment page today online or Email this form and mail a check or call the office Enter Dues $ Additional SeatsSelect Seat TypeMember SeatsNon Member SeatsQuantityBuilding Maintenance Fund $ Total:Congregation Anshe Sholom2018-2019 Membership Application/DuesYahrzeit(Please list name, relationships and dates)Your info is submitted to the office when you hit submit. You can call the office at 914-632-9220 to pay by phone or you can go to the payment page to pay online with your credit card or Paypal. We are happy to receive your check in the mail as well.THANK YOUSubmitReset