- new map!

Please note that a PDF version of this form is also available to ensure that it prints on one page only; just click this link.

If you would like to entrust Rabbi Gurkow with the sale of your Chametz please fill out the form below and bring it or mail it to:

Rabbi Gurkow

543 Huron St., London, Ontario, N5Y 4J6

You may also e-mail a completed copy of this form to Rabbi Gurkow

Remember that all emails must be in no later than Tuesday, April 11, 2006

Please return this form as early as possible as responsibility cannot be accepted for forms received after April 11, 2006.

CERTIFICATE AUTHORIZING THE SALE OF CHAMETZ

Please print neatly or type, as illegible forms cannot be processed.

I (we)*

Hereby authorize Rabbi Eliezer Gurkow to dispose of all Chametz that may be in my (our) possession wherever it may be - at home, at my (our) place of business, or elsewhere - in accordance with the requirements of Jewish law as incorporated in the special contract for the sale of Chametz.

Residence Address

Apt. No. City Province Postal Code

Business Address

Suite No. City Province Postal Code

Please describe the area(s) in your home/office that contain(s) the Chametz:

Signature(s)

Must be signed by head of household and, preferably, by all parties

Phone

Fax

E-mail

* Husband and wife should specify separate names