St. Mary’s Malankara Orthodox Syrian Church, Inc.

99 Park Avenue, White Plains NY 10603

Tel: 516 922 3127

APPLICATION FOR MEMBERSHIP

Name of the Applicant: ______________________________________    Gender _____________

Social Security No      : ______________________________________

Current Address in U.S.A                                       Address in India

______________________________________   ______________________________________

______________________________________   ______________________________________

______________________________________   ______________________________________

______________________________________   ______________________________________

Home Tel: _____________________________   Office Tel: ______________________________

Name and Address of Home parish in India:  ___________________________________________

_____________________________________________________________________________

Marital Status:     Single: o   Married: o   Widowed: o  __________________________________

If married Place & Date of Marriage: _________________________________________________

Are you a dues-paying member of another parish in U.S.A at present?

If Yes, Name & Address of parish: ___________________________________________________

List all family members living with you (including yourself)

First Name                      Last Name                  Gender         Relationship             Date of Birth

                                                                                                                (Mon/Day/Year)

__________________   _________________ _________  ___________________ ___________

__________________   _________________ _________  ___________________ ___________

__________________   _________________ _________  ___________________ ___________

__________________   _________________ _________  ___________________ ___________

 I here by certify that the facts given are true to the best of my knowledge and that on behalf of my family, I agree to pay required dues on  time to keep my membership. I pledge to abide rules and regulations set by the board of trustees of St. Mary’s Malankara Orthodox Syrian Church Inc. The annual membership fee of 500 should be included with membership application form

o Check for one year subscription enclosed (Please make check payable to St. Mary’s Malankara Orthodox Syrian Church Inc)

Date: _________________________                                  Signature: _______________________

                                                       For official use only

Application approved: Yes o    No    o                          Date: _____________________________

                                                                                      __________________________________

Board of Trustees:  President/Secretary/Treasurer           Signature of approving authority.