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Published on solel.org (http://solel.org)

New Member Commitment

Please fill in all the information below. The Ongoing Improvements payment may be spread over six years and can be deferred for the first year of membership. Dues are an annual commitment.

	Contact Information
Name: *
Address: *
City, State, Zip: *
Phone: *
E-mail: *
Confirm E-Mail: *
	Ongoing Improvements Fund - $3,000
Payment Over: *
Beginning: *
Payment By: *	Check Bank Account Debit (information below) Charge Card (information below)
	Total Dues Pledge Amount - $3,035
Dues Payment: *
Other Schedule:
Payment Method: *	Check Bank Account Debit Charge Card Stock Transfer

Check Amount: *

$

Debit Amount: *	$
Routing Number: *	9 digit number at bottom of your check
Bank Account: *

Stock Name: *
Number Of Shares: *
	Please direct your broker to send to: First Midwest Bank, DTC# 0075 into Congregation Solel Acct # 19324342.

Charge Card: *
Account Number: *
Expiration Date: *
Amount: *	A 3% service fee will be added
Authorized Signer: *

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