Last Name: |
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First Name: |
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Address: |
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City: |
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State: |
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Zip Code: |
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Current
country of residence: |
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Home telephone: |
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Work
telephone: |
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Cell
telephone: |
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E-mail
address: |
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If you are filling
this Form out on behalf of another person, please indicate your relationship
to him/her. |
Relationship: |
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SECTION II. FAMILY REGISTRATION
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FATHER'S FAMILY
LAST NAME: |
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MOTHER'S
MAIDEN NAME |
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FATHER'S FIRST
NAME |
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MOTHER'S FIRST
NAME |
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CHILD'S FIRST NAME |
1 |
CHILD'S FIRST NAME |
2 |
CHILD'S FIRST NAME |
3 |
CHILD'S FIRST NAME |
4 |
CHILD'S FIRST NAME |
5 |
CHILD'S FIRST NAME |
6 |
SECTION III. COUNTRY OF ORIGIN
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Country of Origin: |
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Name
of Village, Town or City In Country of Origin? |
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Occupation? |
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Year of Departure? |
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Where
did person go after leaving country of origin? |
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How
long did they stay there? |
Years
Months |
Where did they finally resettle? |
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PLEASE NOTE: Upon completion of this Online
Registration Card, a full Registration Form
will be sent to you, where you can fill out the details of your loss.
Below, please make a brief listing
of any assets confiscated
or abandoned in the country of origin.
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Family
Assets:
Information
on homes, business, property, bank accounts, pensions, or other assets
you lost:
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Communal Assets:
As we attempt to document the existence of a community
that no longer exists, we would appreciate information about any community
resources. This includes any information on communal property
that was left behind, such as schools, hospitals, synagogues, mikvahs,
cemeteries, etc.
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Would you like to receive the full
Registration Form by |
Postal Mail
Email |
Would you like a volunteer to help
you fill out the full Registration Form? |
Yes
No
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Would you be willing to be interviewed
about your family history/experience? |
Yes
No
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We
will respect your privacy and all personal information will be kept
completely confidential.
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