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Yeshivat Dvar Yerushalayim – The Jerusalem Academy of Jewish Studies POB 5454 Jerusalem, Tel: 6522817, Fax: 6522827 Student Application

Surname _____________________________________________________________________

First Name_____________________________________________________________________

Home Address _________________________________________________________________

Address in Israel _______________________________________________________________

Home Telephone No. ________________________ Telephone No. in Israel________________

Date of Birth _____________________________ Place of Birth ________________________

Nationality/s _________________________________________

Passport No. ____________________ Country of Issue of Passport ____________________

Teudat Oleh No. _________________ Teudat Zehut No. _____________________________

Attach photo copies

Marital Status ______________________ No. of Children ______________

Father’s Name ______________________ Occupation _________________

Mother’s Name _____________________ Occupation _________________

Education (Jewish & Secular) and Work (from age 15)

School, Yeshiva, University or Place of work

Year Began

Year Finished

Degrees, diplomas, other qualifications

Knowledge of Hebrew: Reading ___________________ Speaking _______________________

Extra-curricular interests and activities ______________________________________________

Reasons for wishing to attend the Academy __________________________________________

______________________________________________________________________________

Medical Insurance ______________________________________________________________

Present Doctor (Name, Address & Tel. No.) __________________________________________

Relative in Israel: Name: __________________ Address ____________________________

Tel. No. _______________________ Relationship: ______________________________

Period you wish to attend: From:__________________ To:_____________________________

Do you request dorm? ________________________

I agree to pay ____________________ tuition

Date ______________________ Signature ___________________________

For office use __________________________________________________________________