Beth Israel Dues Pledge Form

2010 – 2011

Check all boxes that apply:

□ New Member

□ New Address

□ New E-mail

First Adult

 

Last name

First Name

Middle Name or Initial

Second Adult

 

Last name

First Name

Middle Name or Initial

Address________________________________________________________________________

City__________ Zip_________ Phone_________________E-mail(s)______________________

› I give permission for my e-mail address to be published in the Synagogue Directory.

› Do not publish my e-mail address in the Synagogue Directory.

 Do not publish my child(ren)’s birthdate in the Membership Directory.

I pledge the following amount for my 2010-2011 Beth Israel dues $______________

USCJ (United Synagogue) dues: None if pledge is up to $190

$34.75if pledge is $191-$499

$69.50if pledge is $500 or more

PLUS My USCJ dues will therefore be: $______________

My total synagogue dues and USCJ pledge is: $_______________

œ I am enclosing my first payment of: $_______________

œ I am enclosing a Building Fund payment of: $_______________

Total enclosed $_______________

Your building fund assessment of $200 per year, if you have not yet paid it off, is automatically due on a quarterly basis (at least $50 per quarter). You may pay all or part of it at this time. Please indicate on the check how much of the payment is for the building fund. (Please call the office if you have any question about your current obligation.) New members are responsible for this assessment after one year of membership.

My payments will be made on the following basis:

› Annual › Semi-annual › Quarterly › Monthly.