This is a secure form. (Uses 128 Bit SSL Encryption to protect credit card numbers.) 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 $ Name: Address: 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] This page uses 128 bit SSL encryption to keep your data secure.