Tefillin Bank Form

Your Info

First Name

Last Name

Hebrew Name

Example: David or דוד

Hebrew Name of Mother

Birth Date

Month

Day

Year

Phone Number

Street Address

City

Postal Code

State/Province

Which is your dominant hand?

Right-handed

Left-handed

I hereby affirm that I will attempt to put on the tefillin every weekday.

Note: Please be advised that by filling out this application, it creates no guarantee that you will receive a pair of tefillin, nor does Chabad of West Village make any covenants, guarantees, or contracts with any or all applicants. This application does not constitute a contract of any kind nor does it contain any type of consideration in exchange for receiving a pair of tefillin. If for whatever reason, you decide to no longer use the pair, please return the tefillin to the Chabad of West Village Tefillin Bank so that it be given to another individual. Please be advised that only applicants with a permanent residence in the Village area of New York within the United States will be considered to receive a pair of tefillin.

Chabad West Village