Mezuzah Interest Form
Just moved in and need a Mezuzah to complete the job?
Chabad is happy to provide Mezuzahs, on loan, to all students!
All you need to do is fill out this form and give a $10 deposit. This deposit will be returned to you when you hand your Mezuzah back in at the end of the year.

After you submit your form, we'll be in touch to work out a good time to swing by :)
Sign in to Google to save your progress. Learn more
Full Name *
Email address *
Phone number *
What year are you? *
What's your address on campus? *
Why do you want a Mezuzah? *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy