Mezuzah order form

Fill out the FREE kosher Mezuzah form below.
We will contact you to schedule a time to stop by and affix your new Mezuzah joining millions of Jews and over three thousand years of tradition.

Full Name*

First Name Last Name

E-mail*

Phone Number*

I am a*

Jewish community memberJewish Student at William & Mary

Year graduating

Note for Students: There is a $15 deposit We will ask when placing the Mezuzah.
This deposit will be refunded when you return the Mezuzah at the end of the year.

Address for Mezuzah*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

I would like*

A FREE Kosher Mezuzah on my front door.To purchase several more (beyond the first free one)

How many Mezuzah $60 each

Contribute to this project* Enabling others to have a Kosher Mezuzah

Yes, count me in!Not at the moment

Amount

Payment

Credit Card Paypal

Postal / Zip Code

Country

Total

$60.00

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