Certificate of Personal Status Application Form

Applicant

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone (Mobile or Home) *

Alternative Phone (Mobile or Home)

Hebrew Name (If known)

Email *

Are you the adopted, surrogate, or natural child of your parents?

Shevet

Cohen
Levi
Yisrael

If known

Were you or either of your parents converted to Judaism or adopted?

Yes
No
Unsure

If Yes or Unsure, please detail

You can also upload supporting documents at the end of this form.

Were any of your grandparents or great-granparents coverted to Judaism or adopted?

Yes
No
Unsure

If Yes or Unsure, please detail:

You can also upload supporting documents at the end of this form.

Were any of your parents, grandparents, or great grandparents intermarried?

Yes
No
Unsure

If Yes or Unsure, please detail:

You can also upload supporting documents at the end of this form.

How many years have you lived in the USA?

Selected Value: 1

Family Information

Mother's Name: *

First

Last

Mother's Maiden Name: *

Mother's Hebrew Name:

Mother's Place of Birth: *

Maternal Grandmother's Name: *

Maternal Grandmother's Hebrew Name:

Maternal Grandmother's Place of Birth:

Father's Name: *

First

Last

Father's Shevet (If known)

Cohen
Levi
Israel

Paternal Grandfather's Full Name: *

Paternal Grandfather's Hebrew Name

Paternal Grandfather's Place of Birth: *

Paternal Grandmother's Full Name:

Paternal Grandmother's Hebrew Name:

Paternal Grandmother's Place of Birth

Paternal Great-Grandmother's Place of Birth

Name of Synagogue Where Parents were Married

Date Parents Were Married *

Was either of your NATURAL parents divorced, or did they have a marriage annulled, prior to your birth? *

MARITAL STATUS

Have you ever been married previously, civilly or religiously? *

Yes?
No?

Place and Date of the Wedding

How was the marriage dissolved?

Any additional Information the cRc should be aware of? (Optional)

You can also upload supporting documents at the end of this form.

Were either of your grandmothers divorced? *

Signature *

Please upload any supporting documents for this application.

Click or drag files to this area to upload.

You can upload up to 20 files.

Please upload:

 A passport type photo.

 Copy of birth certificate.

 Passport or other I.D. with picture and ID number

 A signed letter from the applicant declaring that you have never been married, civilly or religiously. If you have been married previously, please phone our
office and the Rabbinic Administrator will guide you in completing the application.

 Two letters from Jewish friends, acquaintances, or business associates, declaring that you are known to them as Jewish, single, and never previously married.
These letters may be handwritten, but must appear on a letterhead or stationery indicating where the person may be contacted for verification of the information.

 One Jewish friend or relative may be required to come to our office to sign the above letter in our presence.

 (If available and/or required) Copies of any additional documentation, e.g. parents’ ketuba, grandparents’ ketuba, birth certificates, burial information, et al.