Memorial Board Plaque Form

Having a plaque for your loved remembered onesMemorial_Board
on the Memorial Board is a way of having them
spend the High Holidays and Yizkor Services with you.

* The Memorial Board Plaque includes:
-A plaque on the Memorial Board.
-A lit light by the plaque for the entire month of Yahrtzeit.
-A yearly reminder letter for Yahrtzeit.
-Mention in Yizkor Prayers (4 times a year. Yom Kippur, Sukkot, Pesach, Shavuot)
* Price for Memorial Board Plaque is $360
(one time fee), with payment options if needed. 

SPONSOR Information:                                                                                          *- required field
* First Name:   *Last name
* Billing Address: 
* City:  * State: *Zip Code:
* Telephone:  * E-mail:

Deceased's Information:
* Relationship to Sponsor: Father Mother Husband Wife Other:
* First Name: * Last name
* Hebrew Name:  Father's Hebrew Name
Mark applicable: Cohen   Levi   Israel
* Date of Passing (mm/dd/yyyy)
* Time of Passing: Day      Night      if Evening, time PM

Form of PAYMENT: Credit Card              Check
If you chose Credit Card: * Credit Card Type:  
* Credit Card Number  * Expiration date
* Cardholder's Name:
* Billing Zip Code  * CCV (Security Code)

Payment Plan: The entire amount is a single payment - $360
                      The entire amount in two equal installments - $180 each
                                 Please date Checks  for a month apart. Credit Card will be charged in two consecutive months.

Memorial Plaque Order will not be processed without payment.