Guided Aliyah Last Name, First Name Preferred Aliyah Month: City of Residence City City of Origin City, State/Province Month Year Email Address

Name of Applicant Guided Aliyah Last Name, First Name Preferred Aliyah Month: City of Residence City City of Origin City, State/Province Month Year Email Address

Aliyah Services Application

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Units:

Date Received:

For Internal Use Only GASO_041116 Nefesh B'Nefesh Services Nefesh B’Nefesh aims to ease the financial burden associated with Aliyah by providing a financial buffer for Olim and helping supplement the requisite relocation expenses, thereby alleviating the somewhat prohibitive costs of Aliyah. We provide support to our Olim both before and after their Aliyah for employment, social services and government assistance, in order to help make their Aliyah as seamless and successful as possible. Below is a brief description of the services and resources available to Olim.

Financial Aid Guidance and Community Resources The financial commitment of pilot trips, securing a Our Guidance and Community Resources Department home, acquiring and shipping household appliances and provides guidance or referrals in matters of education, furnishings can be challenging. To obviate these fiscal community, summer programs, ulpanim and physical or obstacles, Nefesh B'Nefesh provides financial assistance mental health. It also assigns buddy families to help Olim to eligible individuals and families to enable them to in the inital stages of their klita. make their dream of Aliyah a reality. Online Resources Pre-Aliyah NBN Website: We are constantly updating our website Our Pre-Aliyah Department assists Olim in all areas with Aliyah resources, contacts and useful information of their Aliyah planning. Our expert Pre-Aliyah staff and links. Find us at www.nbn.org.il answer all questions regarding the Aliyah process. This NBN Yahoo Group: We have set up a Yahoo department is also responsible for grant allocations and discussion group for our applicants and veteran Olim for overseeing the application review process. for exchanging advice, contacts and community Employment information. To sign up, email: [email protected] Our Employment Department helps Olim who are seeking assistance in finding employment, job retraining, career NBN Singles Yahoo Group: There is a unique Yahoo development, or professional mentoring. group specifically for Single Olim: To sign up, email: Absorption - Klita [email protected] Our Absorption Department is ready to assist Olim with questions regarding Oleh benefits, government processing, or any other aspect of their absorption. The answers to many frequently asked questions about Aliyah and benefits can be found on our website (see below).

Eligibility for Guided Aliyah Before applying for Guided Aliyah please read the following guidelines to confirm that you are eligible to participate in the Guided Aliyah program.

Applicants must be citizens of the United States or If you converted to Judaism in North America: Canada and hold valid passports from one of these two Misrad Hapnim policy requires that you must reside in the countries. community in which you converted for a period of at least one year before being eligible to make Aliyah. If you have: • Converted to Judaism in Israel If you are applying for Aliyah with a newborn child recently born in Israel (who was not registered as an Israeli • An Israeli passport or were born abroad citizen at the time of their birth) you will have to have a to an Israeli parent US, Canadian or UK passport issued for that child before • A birth certificate from the former Soviet Union or submitting your application. Eastern Bloc If your spouse is an Israeli citizen, and you have children • Renounced Israeli citizenship at any time in the past born abroad, please contact our Absorption Department in • Previously been convicted of a crime order to clarify whether or not your children are considered Israeli citizens and to determine if they are eligible to Misrad Hapnim guidelines dictate that you CANNOT be participate in the Guided Aliyah program. processed through the Guided Aliyah program. In order to apply for Nefesh B'Nefesh assistance, please download and submit an Aliyah via Misrad Hapnim application and contact your local branch of Misrad Hapnim to schedule an appointment to begin the Aliyah process. Application Instructions (Page 1 of 2) Do not submit your application until all of the following steps are complete. Please allow 10 weeks for processing. Misrad Hapnim Material Passport Photocopies Please complete the enclosed material from Misrad Hapnim Please submit a copy of the main page of your US or (Israeli Ministry of Interior). These forms MUST be filled Canadian passport (the page which includes your out by all family members age 16 and over making Aliyah. picture) and that of everyone in the family who is making Please photocopy this section as necessary. Aliyah. Please include photocopies of all pages indicating “Application for Oleh status” form needs to be filled out applicable date extensions, and/or name changes. Your for each family member making Aliyah. passport must be valid for at least six months from your projected date of Aliyah. Photo Enclose a recent color photo of all individuals making Passport Photos Aliyah. Families: Enclose one picture which includes all Please include two official and identicalpassport photos family members together. Singles: Enclose a photo of the of each family member age 16 and over who is making applicant only. Aliyah. The photos should be in color, 35 mm wide by 45 mm high, front view, ears showing, and on a blue or Application white background. Please print the full name of each Please submit your original application and copies of all Oleh on the back of each photo. requested documents. Please retain an additional copy of all paperwork for yourself. 35 mm Application Fee Application must be accompanied by a check (made payable to Nefesh B’Nefesh) or cash payment in the amount of 100.00 NIS. Head dimensions Please Note: The application fee is non-refundable. 45 mm 25 mm wide 35 mm high Birth Certificates Please submit copies of the official birth certificatesNOT ( a Consular Report of Birth Abroad) for all family members making Aliyah. The birth certificate must list your parents’ names. If the birth certificate is not inEnglish or Hebrew, please submit a notarized translation into English or Hebrew with a copy of the birth certificate. Application Instructions continued Certificate of Marital Status on the next page Please submit a copy of relevant documentation according to [ your marital status, i.e.: civil marriage certificate, divorce certificate, or death certificate of spouse. All civil documentation issued after September 1, 1988 must be submitted with accompanying apostille certification. If the marital status certificate is not in English or Hebrew, please submit a copy of a notarized translation into English or Hebrew with a copy of the marital status certificate. Teudat Yosher The Ministry of Interior requires that all Aliyah applicants age 16 and over obtain a Letter of Good Standing (Teudat Yosher) from the authorities in their country of origin (issued by the country/state/provincial police) certifying that the applicant has no criminal background. Please make sure to have all original Apostille certification (also called a chain of signatures or legalisation) must be affixed to the original Letter of documents in your possession by the time Good Standing. Guided Aliyah applicants who are unable you submit your application. to obtain this documentation may submit a declaration signed in the presence of an Israeli lawyer in lieu of the PLEASE NOTE: Misrad Hapnim reserves the police record. Please find the declaration form attached to right to ask for additional documents. the back of this application. Application Instructions (Page 2 of 2) Do not submit your application until all of the following steps are complete. Please allow 10 weeks for processing. Acceptable Proof of Judaism For Parents of Minor Children Please submit a copy of one of the following: • If you are making Split Aliyah (where one spouse 1) Signed letter in English or Hebrew from a recognized makes Aliyah and one does not), Misrad Hapnim Rabbi in North America on official synagogue letterhead, requires a notarized letter of consent from the par- which states the following: ent who is NOT making Aliyah authorizing his or her • Name, location and telephone number of congregation spouse to make Aliyah with their children. Please • Applicant’s full name and parents’ names submit a copy of this letter with your application. • Applicant (and spouse, if applicable) is Jewish and born to a Jewish mother If you or your spouse has minor children from a previ- If you are Jewish through your father/grandfather, please • provide a letter from a recognized Rabbi in North America ous marriage, Misrad Hapnim requires a notarized who can confirm your Jewish heritage. letter of consent from the child’s other parent authoriz- 2) Conversion Certificate from a recognized Beit Din ing you to make Aliyah (in addition to a copy of your (Rabbinical Court). The certificate must be signed by the divorce agreement/custody order). If the child in ques- three members of the officiating Beit Din. tion is making Aliyah, the letter will need to state that In addition to your conversion certificate, please submit the child is permitted to obtain Israeli citizenship. You two accompanying letters, as follows: will need this letter whether your children are making Aliyah with you or not. Please submit a copy of this A) A letter from the rabbi with whom you studied in letter with your application. preparation for your conversion. The letter must appear on synagogue letterhead and describe the following: • Details of your conversion process • Where you studied (e.g. organization name) • Relevant dates • Community involvement • If you have children, indicate if they were born before or after your conversion Important note: Please read! B) Please submit a letter detailing your decision to convert to Please DO NOT submit original documents Judaism and your involvement in the Jewish community with your application to Nefesh B’Nefesh. since the completion of your conversion process. Please DO bring original documents to your interview with Misrad Hapnim. They will request originals of the following: • Birth Certificate(and notarized translation if applicable) • Civil Marriage/Divorce/Death Certificate with apostille certification (if applicable) • Proof of Judaism • Valid US or Canadian Passport • Letter of Good Standing (or declaration from a lawyer) • Notarized letter of parental consent (if applicable) You will need to present these documents to the Misrad Hapnim representative at your interview on a date to be determined. Misrad Hapnim CANNOT process your application without seeing your original documents. Misrad Hapnim will not accept photocopies/faxes. Please note: Misrad Hapnim reserves the right to request additional documents or an interview.

Nefesh B'Nefesh - Aliyah Services Application - Guided Aliyah Program Page4 Applicant Information For the purposes of your Aliyah processing, please designate one adult in the family as the Primary Applicant and the second adult (where applicable) as the Spouse. 1Section A of this application should be filled out by the Primary Applicant and Section B by the Spouse. A: Primary Applicant Information

Legal Name (exactly as it appears on your passport) Last First Middle Maiden

Preferred First Name Occupation Gender Male Female

Contact Information

Home Phone Work Phone Mobile Phone Email Address Current Address Street Address City Neighborhood Postal Code

Date of Birth Country of Birth If Israel, at what age did you leave Israel? MM/DD/YYYY

Married Single Divorced Charedi Orthodox Masorti Reform Marital Status Widowed Separated Engaged Jewish Affiliation Liberal Unaffiliated Other Important: Please submit a photocopy of your civil marriage, divorce or spouse’s death certificate, if applicable.

Are you an Israeli citizen? Yes No If yes, what is your Mispar Zehut (Israeli ID #)?

Have you ever held an A1 Visa (Temporary Resident)? Yes No If yes, FROM TO MM/DD/YYYY MM/DD/YYYY If so, what is your 9-digit Israeli ID Number?

Country of Citizenship Please list all countries to which you hold citizenship.

Have you started the Aliyah process Yes No If yes, I opened a tik with Misrad Hapnim Jewish Agency

Date you moved to Israel: How long have you been living in Israel in the past seven years: MM/DD/YYYY Mother's Name: Date of Birth: Father’s Name: Date of Birth: MM/DD/YYYY DD/MM/YYYY Are either of your parents Israeli citizens? Father Mother Neither

Have either of your parents made Aliyah? Mother Date 9-Digit Teudat Zehut No. MM/DD/YYYY Father Date 9-Digit Teudat Zehut No. MM/DD/YYYY

Are you making Split Aliyah? Split Aliyah is when one spouse makes Aliyah and the other spouse will change their status to Oleh at a later date. This is applicable whether or not you have children. Yes No If yes, which spouse is making Aliyah?

Do you or your spouse have minor children not accompanying you on Aliyah? Yes No

If yes, please explain:

Please confirm the total number of family members, including yourself, officially making Aliyah:

Nefesh B’Nefesh website Community Poster Online Word of mouth How did you hear about the Guided Aliyah program? Advertisment: Please specify publication ______Nefesh B'Nefesh - Aliyah Services Application - Guided Aliyah Program 1 B: Spouse Information - The following info is required even if your spouse is Israeli or not applying for Aliyah. Please submit a photocopy of your civil marriage certificate Legal Name (exactly as it appears on your passport) Last First Middle Maiden Preferred First Name Occupation Gender Male Female Date of Birth MM/DD/YYYY Country of Birth If Israel, at what age did you leave Israel?

Are you an Israeli citizen? Yes No If yes, what is your Mispar Zehut (Israeli ID #)?

Have you ever held an A1 Visa (Temporary Resident)? Yes No If yes, FROM TO MM/DD/YYYY MM/DD/YYYY If so, what is your 9-digit Israeli ID Number?

Have you started the Aliyah process Yes No If yes, I opened a tik with Misrad Hapnim Jewish Agency Country of Citizenship Please list all countries to which you hold citizenship. Date you moved to Israel: How long have you been living in Israel in the past seven years: MM/DD/YYYY Mother's Name: Date of Birth: Father’s Name: Date of Birth: MM/DD/YYYY MM/DD/YYYY Are either of your parents Israeli citizens? Father Mother Neither

Have either of your parents made Aliyah? Mother Date 9-Digit Teudat Zehut No. MM/DD/YYYY Father Date 9-Digit Teudat Zehut No. MM/DD/YYYY C: Children Please provide the information below, if applicable. Please enter full names, as they appear on your children’s passports.

Child 1 Male Female Yes No Last Name, First Name, Middle Name (as appears in passport) Gender DOB: MM/DD/YYYY Country of Birth Will this child be making Aliyah with you?

Child 2 Male Female Yes No Last Name, First Name, Middle Name (as appears in passport) Gender DOB: MM/DD/YYYY Country of Birth Will this child be making Aliyah with you?

Child 3 Male Female Yes No Last Name, First Name, Middle Name (as appears in passport) Gender DOB: MM/DD/YYYY Country of Birth Will this child be making Aliyah with you?

Child 4 Male Female Yes No Last Name, First Name, Middle Name (as appears in passport) Gender DOB: MM/DD/YYYY Country of Birth Will this child be making Aliyah with you?

Child 5 Male Female Yes No Last Name, First Name, Middle Name (as appears in passport) Gender DOB: MM/DD/YYYY Country of Birth Will this child be making Aliyah with you?

Child 6 Male Female Yes No Last Name, First Name, Middle Name (as appears in passport) Gender DOB: MM/DD/YYYY Country of Birth Will this child be making Aliyah with you?

Child 7 Male Female Yes No Last Name, First Name, Middle Name (as appears in passport) Gender DOB: MM/DD/YYYY Country of Birth Will this child be making Aliyah with you? Personal Profile For the purposes of your Aliyah processing, please designate one adult in the family as the Primary Applicant and the second adult (where applicable) as the Spouse. Section A of this application should be filled out by the Primary Applicant and Section B by the Spouse. 2A: Primary Applicant Name List any Jewish groups, camps, and/or organizations you have been affiliated with:

History of Experience in Israel Please provide details and dates of your prior visits and time you have lived in Israel on the lines below.

Nefesh B'Nefesh - Aliyah Services Application - Guided Aliyah Program 2 What family do you have in Israel?

Have you ever served in the IDF or any other armed forces? None IDF Machal Other - please specify:

If you served in Machal, what is your 9-digit Israeli ID Number? FROM TO MM/DD/YYYY MM/DD/YYYY Are you planning to serve in the Israeli Defense Force after your Aliyah? Yes No

Have you participated in a MASA program: Yes No If so, what year and what program? Education High School Name of Institution City Location Years Attended Degrees Attained College/University e.g. 1987-1991 Yeshiva Gedola/Seminary Name of Institution City Location Years Attended Degrees Attained e.g. 1991-1995 Post-College/Kollel Name of Institution City Location Years Attended Degrees Attained e.g. 1995-1999 Employment History

I am currently Employed Unemployed Studying Retired Please list your last two jobs, beginning with the most recent: Job 1 Company name Position Held Start Date End Date

What did you like most about this position? What did you like least about this position? Job 2 Company name Position Held Start Date End Date

What did you like most about this position? What did you like least about this position?

Please rate your knowledge of Hebrew: Please circle (poor) 1 2 3 4 5 (fluent) Please circle (poor) 1 2 3 4 5 (fluent) Please circle (poor) 1 2 3 4 5 (fluent) Reading Speaking Writing Are you planning on studying in a Hebrew language Ulpan? Yes No

Jewish Lineage Were you born to a Jewish mother? Yes No If no, please indicate which of the following options applies to you: My father is/was Jewish One of my grandfathers is/was Jewish My spouse is Jewish (non-Israeli) I converted to Judaism None of the above

Have you or anyone in your family converted to Judaism? Please specify: Self Spouse Mother Father Children None

If so, please indicate the dates of conversion & to whom they apply: MM/DD/YYYY NOTE: Please submit a copy of all conversion documents with application. If any of these conversions took place in Israel, please indicate which conversions: PLEASE NOTE: If you converted to Judaism in Israel, you MUST process your Aliyah at the Misrad Hapnim in Israel.

Have you ever been convicted of a felony? Yes No If yes, in which state: Please explain:

Are you currently involved in any legal proceedings? Yes No If yes, please explain:

Nefesh B'Nefesh - Aliyah Services Application - Guided Aliyah Program 3 List any stressful events you have experienced over the past two years:

Note: This will not affect eligibility for acceptance to NBN, but will allow us to guide you more concretely through your Aliyah. Are you or any members of your immediate family listed on this application currently taking medications? Yes No

Please list all medications:

Please state the main reasons why you would like to make Aliyah: (Use back of this page if you need more room)

B: Spouse - Complete only if spouse is making Aliyah Name

List any Jewish groups, camps, and/or organizations you have been affiliated with:

History of Experience in Israel Please provide details and dates of your prior experience(s) in Israel on the lines below.

Have you ever served in the IDF or any other armed forces? None IDF Machal Other - please specify:

If you served in Machal, what is your 9-digit Israeli ID Number? FROM TO MM/DD/YYYY MM/DD/YYYY

Are you planning to serve in the Israeli Defense Force after your Aliyah? Yes No

Education High School Name of Institution City Location Years Attended Degrees Attained College/University e.g. 1987-1991 Yeshiva Gedola/Seminary Name of Institution City Location Years Attended Degrees Attained e.g. 1991-1995 Post-College/Kollel Name of Institution City Location Years Attended Degrees Attained e.g. 1995-1999 Employment History

I am currently Employed Unemployed Studying Retired Please list your last two jobs, beginning with the most recent: Job 1 Company name Position Held Start Date End Date

What did you like most about this position? What did you like least about this position? Job 2 Company name Position Held Start Date End Date

What did you like most about this position? What did you like least about this position? Nefesh B'Nefesh - Aliyah Services Application - Guided Aliyah Program 4 Please rate your knowledge of Hebrew: Please circle (poor) 1 2 3 4 5 (fluent) Please circle (poor) 1 2 3 4 5 (fluent) Please circle (poor) 1 2 3 4 5 (fluent) Reading Speaking Writing Are you planning on studying in a Hebrew language Ulpan? Yes No

Have you or anyone in your family converted to Judaism? Please specify: Self Spouse Mother Father Children None

PLEASE NOTE: If you converted to Judaism in Israel, you MUST process your Aliyah at the Misrad Hapnim in Israel.

Have you ever been convicted of a felony? Yes No If yes, in which state: Please explain:

Are you currently involved in any legal proceedings? Yes No If yes, please explain:

List any stressful events you have experienced over the past two years:

Please list all medications:

Please state the main reasons why you would like to make Aliyah: (Use back of this page if you need more room)

Nefesh B'Nefesh - Aliyah Services Application - Guided Aliyah Program 5 References Please provide us with the names and contact information of people (non-relatives), either in North America, the United 3Kingdom or in Israel, who have known you for more than two years and who we can call upon as references for you. Reference (Israel): Name Address Phone number Reference Description

Reference (North America): Name Address Phone number Reference Description

If you are retired and have children in Israel, please list:

Name Address Phone number

4Signature I/We hereby certify that all answers which I/We have provided in this application are truthful and correct. Primary Applicant Signature Date

Secondary Applicant Signature Date Complete this checklist before submitting your application Original application, including copies of requested documents Application fee Copy of each applicant’s birth certificate (with parent’s names listed)

Copy of a letter from your rabbi, or Mail your completed application to: conversion certificate, as applicable Nefesh B'Nefesh Two official, identical passport photos of each applicant age 16 and over (please write Attn: Guided Aliyah Department name of applicant on back of each photo) Beit Ofer Photo of all family members making Aliyah 5 Nachum Hefzadi One photocopy of each applicant's passport Jerusalem, 95484

Copy of certificate of civil marriage, divorce, or death, apostille certification, as applicable Parents' names and dates of birth (p. 1) Completed Misrad Hapnim material Letter of Good Standing (or declaration from a lawyer)

Nefesh B'Nefesh - Aliyah Services Application - Guided Aliyah Program 6 Disclaimer

I, the undersigned, ______, of ______, (insert address), have read the following statement and understood it, and do hereby agree to its terms and conditions.

I understand that Nefesh B’Nefesh is a non-profit organization whose purpose is to aid and assist new immigrants who require information and assistance regarding various questions concerning their absorption in Israel.

I understand and agree that I have not, and shall not have, at any time in the future, any claims of any kind against Nefesh B’Nefesh and/or its employees individually and/or collectively, who do not and shall not bear any liability, whatsoever, for any act or omission in relation to any advice given to me or any counseling services, and/or personal accompaniment which Nefesh B’Nefesh or its employees shall provide; or any advice of a general nature which Nefesh B’Nefesh or its employees shall provide me.

For the sake of clarity, I hereby declare that I know that Nefesh B’Nefesh gives only primary advice, since they are not lawyers, custom agents or governmental officers. I am aware that for further advice I will need to consult with the relevant governmental agencies or with experts in the field. Any advice or services that Nefesh B’Nefesh may provide me are at my own risk, and I hereby irrevocably relinquish any claim which I may have, or will have, at any time, in relation to any of the above. I further declare that Nefesh B’Nefesh (in partnership with the Jewish Agency) is the sole organization providing me with pre-Aliyah support services.

For the purpose of assisting in my Aliyah, I understand that some of the information I have relinquished to Nefesh B’Nefesh may be shared with the Jewish Agency for Israel and the Government of the State of Israel.

I have read and understood all of the contents of this disclaimer, and hereby agree to all of its terms and conditions. My agreement also represents the agreement to the above of all family members in this application. I hereby certify that all answers which I have provided in this application are truthful and correct.

Signed: ______Name: ______Date: ______

Photo Release Photos of individuals making Aliyah sponsored by Nefesh B'Nefesh will facilitate our work and continued efforts of increasing Aliyah from North America. We thank you for your cooperation.

I, the undersigned, ______, of ______(insert address), hereby give permission for Nefesh B'Nefesh to release photographs or videos of myself or my family in promotional or press related literature.

Signed: ______Name: ______Date: ______

Nefesh B'Nefesh - Aliyah Services Application - Guided Aliyah Program 7 מדינת ישראל - משרד הפנים State of Israel - Ministry of the Interior

Application for New Immigrant/Oleh Status מדינת ישראל - משרד הפנים State of Israel - Ministry of the Interior

STATE OF ISRAEL – MINISTRY OF INTERIORDECLARATION FOR RECEIVING TEUDAT OLEH (OLEH VISA)

Last Name: ______First Name: ______Father’s Name: ______Country of Birth: ______Date of Birth (d/m/year): ______Nationality: ______Passport number: ______

I hereby declare that I have not suffered in the past, or am currently suffering from one of the following illnesses:

1. Mental Illness 2. Drugs or Alcohol addiction 3. Tuberculosis 4. Any other illness which might endanger public health.

I hereby declare that the details above are correct and were given with the knowledge that they are to serve as a basis for the consideration of my application.

I am aware that if I declare false information for receiving my Teudat Oleh, then the Minister of Interior has the authority to cancel my permanent resident license or my Teudat Oleh, according to paragraph 11 in the Law of Entry into Israel - 1952. Cancellation of my Teudat Oleh can result in the cancellation of my Israeli citizenship.

Signature: ______

For the use of the Ministry of Health Staff

I hereby confirm that this declaration was signed before me on ______(date) after being approved for aliyah.

Name of Dr. ______(signature) מדינת ישראל - משרד הפנים State of Israel - Ministry of the Interior Population Authority

Declaration of Religious and National Registration Details According to article 4b of the Law of Return

To The Regional Bureau for the Population Authority in Jerusalem

Completion of Religious and National Registration Details in the Population Registry

______FULL NAME IDENTIFICATION NUMBER

I hereby attest that I am a Jew according to article 4b of the Law of Return and request to register in the detail of the Religion “Jewish” and the Nationality “Jewish” of the Population Registry - my mother is Jewish / I converted* and I am not a member of any other religion.

______PLACE DATE SIGNATURE OF DECLARER

______THE ABOVE WAS SIGNED DATE SIGNATURE OF CLERK IN THE PRESENCE OF מדינת ישראל - משרד הפנים State of Israel - Ministry of the Interior Declaration (This declaration has to be attached to the form requesting change of status)

I, ______the undersigned declare that I have been made fully aware that I am entitled to be in Israel on any of the following visas:

1. On an Immigration Visa (Oleh), by the Law of Return, if I intend to settle permanently in Israel. 2. Or on a Student Visa (A-2), if I intend to come to Israel for the purpose of study only. 3. Or on a Tourist Visa (B-2), if at the present time I do not plan to settle in Israel. 4. Or on a Temporary Resident Visa (A-1), if I intend to explore the possibilities of set- tling in Israel within a period of three years.

Please circle the appropriate option:

I declare that:

1. I have never in the past resided in Israel as an immigrant or as a Temporary Resident (A-1).

2. I have resided in Israel from ______on a ______visa. My identity number was/is ______.

3. My husband/wife resided in Israel from ______on a ______visa. His/here identity number was/is ______.

Signature: ______Date: ______

I hereby confirm that this declaration was signed before me after its contents were read and further reviewed and clarified by me.

Name of the recipient of the statement: ______

Signature: ______Date: ______

This form must be completed for each family member making Aliyah

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. .       

. .       

______  Name

______



 ______/  / ______      / ,   /     ,   /  ,/ . .  / " / 

______ 