Yahrtzeit Memorial Plaque Order Form

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Sample Memorial Plaque Information:
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Below is a sample of the information required for each name submitted:
Name : Walter Cohen Hebrew Name: Moshe Father's Hebrew Name: Avrohom
Date of Passing: September 1, 1989 Hebrew Date of Passing (if Known): Elul 13, 5759
Calculate the Hebrew date of passing here


Part 1: DEDICATION PLAQUE (Information of the person(s) whose memory you wish to honor) I/we would like to dedicate plaque/s.
This information will used to make the plaque; please complete it exactly the way you would like it to appear.
PLAQUE #1		PLAQUE #2
Name		Name
Hebrew Name		Hebrew Name
Father's Hebrew Name		Father's Hebrew Name
Date of Passing	mm/dd/yyyy	Date of Passing	mm/dd/yyyy
Hebrew Date of Passing (if known)		Hebrew Date of Passing (if known)

Part 2: RELATIVE INFORMATION (individual requesting plaque)
First name		Last name
Address		City
State		Zip
Phone		Email

Part 3: PAYMENT DETAILS
The suggested contribution is $600 per Memorial Plaque. A receipt for income tax purposes will be issued.
Name on card		Amount to be charged
Card Number		Card Type
Exp. Month		Exp. Year
Billing Zip		CVV Code	4 digits on the front of Amex. 3 digits on back of Visa and MasterCard.

Alternatively, you may print this form and mail it with a check to:
Chabad at Porter Ranch - 19043 Rinaldi Street, Porter Ranch, CA 91326

Our policy is, and always will be, Open door/No Membership; no one will be turned away due to lack of funds. We hope you will continue to contribute to the extent of your ability, and help Chabad at Porter Ranch continue with its vital work. The 'Tzedakah' - Charity act in memory of a loved one, helps the soul rest in peace and achieve elevation in the heavenly spheres.