Memorial Plaque Order Form: Part 1: Information of the person whose memory you wish to honor (The information in this part is used to make the plaque; please complete exactly the way you would like it to appear) Last name First name English Jewish/Hebrew Date of birth Day Month Year Date of passing Day Month Year Time of passing AM PM Optional Jewish date of passing Day Month Year Check converter Father's first name English Jewish/Hebrew Mother's first name English Jewish/Hebrew Part 2: Relative information (Information of the relative requesting plaque) First name Last name Address Postal code City State Email Relationship to the person that passed away Part 3: Yahrtzeit notification If there are any other additional relatives to be notified before Yartzeit, please list name and address info. Thank you. 1. First & last name Address Postal code City State Country Email 2. First & last name Address Postal code City State Country Email 3. First & last name Address Postal code City State Country Email Part 4: Payment information Our policy is Open door/No Membership; no one will be turned away due to lack of funds, we hope you will contribute to the extent of your ability, and help Chabad of Oxnard with its work. The 'Tzedakah'-Charity act in memory of a loved one, helps the soul rest in peace and achieve a higher place in the world up there. Suggested contribution for a Memorial Plaque is $360 or more. A receipt for income tax purposes will be issued. I prefer another method of payment Please specify: Online Credit Card Payment: Amount $360 Other If needed: Please charge this amount to my Credit Card in instalments of $ each month. Card Type Visa MasterCard American Express Discover Card Number Expiration date 01 02 03 04 05 06 07 08 09 10 11 12 2011 2012 2013 2014 2015 If you have trouble with this form please notify us by clicking here. This page uses 128 bit SSL encryption to keep your data secure.