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Confidential Dues Adjustment Form
Member Information
Your Name
(Required)
First
Last
Your Phone
(Required)
Your Email
(Required)
Spouse/Partner Name
First
Last
Spouse/Partner Phone
Spouse/Partner Email
Dependents
If applicable
Name
First
Last
Age
Enrolled in The Learning Center?
Yes
No
Name
First
Last
Age
Enrolled in The Learning Center?
Yes
No
Name
First
Last
Age
Enrolled in The Learning Center?
Yes
No
Name
First
Last
Age
Enrolled in The Learning Center?
Yes
No
Additional Information
Please note that we will be unable to consider your application without the answers to ALL of the following.
Your Occupation
(Required)
Employment Status
(Required)
Full Time
Part Time
Unemployed
Retired
Employer
(Required)
Gross Annual Income
(Required)
Spouse/Partner Occupation
Spouse/Partner Employment Status
Full Time
Part Time
Unemployed
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Spouse/Partner Employer
Spouse/Partner Gross Annual Income
Extraordinary Expenses
(Required)
Please explain the reason/s you are requesting a dues adjustment.
(Required)
Payment
Preferred Payment Schedule
(Required)
Single Payment
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Payment Method
(Required)
Check
Credit Card
Credit Card Number
Expiration Date
CVV
Billing Street Address
Billing Zip Code
Signature
The above information is exclusively for the confidential records of The Temple-Tifereth Israel.
Date
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Month
1
2
3
4
5
6
7
8
9
10
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12
Day
1
2
3
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5
6
7
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11
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14
15
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17
18
19
20
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28
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31
Year
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1920
Your Full Name
(Required)
This will serve as your digital signature.
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