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Memorial Wall Plaque
Dedication Form

Cost per plaque is $500.00

Name of Deceased; Secular:

Name of Deceased; Hebrew:

Secular Day of Passing; Month/Day/Year:

Jewish Day of Passing; (if known); Month/Day Year:

Name of father of deceased; Hebrew:

Please note: We will be happy to help you convert dates from Hebrew to secular and vice versa.

Please make check payable to: Chabad Lubavitch of Alexandria-Arlington

Please mail this form to: Chabad Lubavitch of Alexandria-Arlington,
1307 N Highland Street, Arlington, VA 22201


Or you can submit this form online and pay by Credit Card below.

Enter amount here $  

City:          State:  Zip:
Phone:      Email:

               VISA MasterCard  American Express

Card No.   Exp:mm/yyyy /

Card ID Number:  Where's my Card ID Number?

Thank you for your generous support.
All contributions are tax deductible.

If you have any questions or concerns please contact our office
at (703) 820-2770 or email [email protected]