Please print this application, complete it, and return it to the synagogue office.
If you have questions, call the shul office at 847-415-1370. If they cannot assist you, they will have someone call you back.

Congregation B'nai Shalom of Buffalo Grove
701 W. Aptakisic Road
Buffalo Grove, Illinois 60089
Phone: (847) 415-1370

MEMBERSHIP APPLICATION AND DUES AGREEMENT
2008-2009 (5768-9)
(Updated 6/16/08)

Part I - Membership Dues and Fees

Membership Dues

To calculate dues, please check the box next to the appropriate classification. Age should be calculated using your family's primary wage earner as of June 1st, 2008.

Regular Annual Dues are payable as follows:

• Approximately 2/3rd due by September 1st (contact the shul for the exact amount)
• Remainder due by December 31st

Early Bird Dues are payable as follows (amounts are approximate - contact the shul for the exact amount):

• 1/3rd due by June 15th
• 1/3rd due by July 15th
• Remainder due by August 15th

Introductory Membership dues are payable in full with this application.

Any modification of the above schedule must be approved, in confidence and in writing by the Dues Review Committee. You may be asked to provide tax returns and other documentation to substantiate financial need.

Building Fund

All new members under 65 yrs. of age are required to contribute to the synagogue building fund, to help us maintain and expand our facilities. Under the new introductory membership plan, building fund may be deferred for one year.

In each shul year, the Building Fund amount may be made in three payments:

• 1/3rd due by April 1st
• 1/3rd due by June 1st
• 1/3rd due by September 1st, prior to High Holidays

Members should remain current with this payment schedule, unless otherwise approved, in order to maintain "Member in Good Standing" status.

Additional Fees and Summary Calculation

Payment Method

[___] Check (payable to "Congregation B'nai Shalom of Buffalo Grove")

[___] Credit Card ( Visa ____ Mastercard ____ )

Card Number: ____________________________________ Expiration Date: ________________

Name on Card: ________________________________________________________________

Acknowledgement of Obligation

The undersigned member acknowledges the total balance owed, and agrees to pay the total amount according to the membership terms and agreements as set forth in the Constitution, Bylaws, Rules, Regulations, Policies and Procedures as amended from time to time.  Further, the undersigned acknowledges that Congregation B’nai Shalom of Buffalo Grove may act in reliance upon this promise to fulfill the necessary financial obligation such that the full amount of dues is payable every fiscal year and that the building fund is due in full and payable as agreed.

Signature: ______________________________________________________ Date: _____________________

Part II - Membership Application Form

The following information is requested of all new members.
Notes: Those questions preceded with an "A" in parenthesis pertain to the head of the household. Those questions with a "B" in parenthesis pertain to the spouse (as applicable). Letters "C" and higher pertain to the children in your family. Questions with no letter in parenthesis pertain to the family as a whole. Please ignore encoding numbers, which are assigned for data entry purposes only.

Please provide the following information for each adult in your family:

(37) Marital Status (Check One): Single ____ Married ____ Divorced ____ Widowed ____

(32A) Please indicate (Check One): Cohen ____ Levi ____ Yisrael ____

(10) Indicate with "A" or "B" title requested on correspondence or letters:
Mr.___ Mrs.___ Miss ___ Ms. ___ Dr. ___ Judge ___ Other ______________________

(12) Name preferred in salutation (e.g. Dave & Sandy, Dr. and Mrs., etc.
______________________________________________________________________

Is your marriage Interfaith? Yes ___ No ___

Going back to your great-grandparents. has there been a conversion in your family? Yes ____ No____

(41) How many children in your family?_______

Please enter the following information for each child. Use additional sheets if you have more than five children.
Include last name below if different from yours.

(38) Are any of your children away at college? If yes, which ones _________________________________

Are any of your children adopted? Yes ___ No ___

Please list services, goods or area of expertise that might be provided to the synagogue:
____________________________________________________________________________________

Please indicate family interests in the following areas:
Use "A" for Head of household, "B" for Spouse and "C", "D", "E" etc. for children:

Yahrzeits

Thank you for completing this application.