Rabbinic Pastors Association (RPA)

Initial Membership Application for Rabbinic Pastors*

If at OHALAH, please give your check and application to Rabbinic Pastor David Daniel Klipper.  Otherwise, please mail the completed application with your check, made out to the Rabbinic Pastors Association, to Rabbinic Pastor Simcha Raphael, 1211 Ansley Avenue, Melrose Park, PA 19027.
Please print legibly or type.

GENERAL INFORMATION

Name:                                                                                                                                 

Hebrew Name:                                                                                                                    

Home address:                                                                                                                    

                                                                                                                                           
City                                    State/Province                        Zip/Postal code            Country

Work address:                                                                                                                     

Name of employer:                                                                               

                                                                                                                                            
Street address or post office box                       
                                                                                                                                              
City                                    State/Province                        Zip/Postal code            Country

Where do you prefer we send RPA correspondence (home or work)?                                   

Home Phone:                                                   Work Phone:                                                 

Cell Phone:                                                Fax No.                                                              

E-mail address:                                                                                                                     

Type of Membership:

Full:  ____            Student:  _____            Dual:  ________            (Note:  Dual membership is only open to individuals who belong and pay dues to OHALAH as well as the RPA.)

Dues Schedule

Annual income                        Full                        Student                        Dual
                                              Dues                        Dues                                    Dues

Over $100,000                       $216                        $144                                    $36

$66,001 to $100,000               $162                        $108                                    $36

$36,001 to $66,000                 $108                          $72                                    $36

$36,000 and under                     $54                          $36                                    $36

ORDINATION

Please attach a copy of your smicha document.  If you have separate Hebrew and English documents, please attach both.  If you are a graduate of the Chaplaincy School at AJR/CA’s chaplaincy program, please submit evidence of graduation.

RECOMMENDATIONS

Please obtain a recommendation regarding your membership.  If possible, this should be from someone known to Rabbinic Pastor Association members.  You may also utilize Rabbinic Pastor Shulamit Fagin or  Rabbinic Pastor David Daniel Klipper at dklipper@stamhealth.org or daviddaniel@klipper.us in support of your application.

PROFESSIONAL ASSOCIATIONS

1.  Do you belong to any professional associations?                            

If so, which one(s)?                                                                                                                                               

• Have you ever been denied membership in a professional association to which you have applied?                                      

• Have you ever been suspended, expelled, placed on probation or been subject to other disciplinary action by a professional association for any reason other than the non-payment of dues?                          

If you answer yes to question 2 or 3, please explain on a separate sheet.

My answers to the above questions are true and correct to the best of my knowledge.  I hereby agree that I am bound by and will comply with the OHALAH ethics policy as it is presented at http://www.ohalah.org/guidelines/OHALAHEthicsPolicy.pdf.

                                                                                                                                              
                        Signature                                                                                    Date

See top of page for where to send this application.