1. ALIYAH QUESTIONNAIRE
For office use:
File number: ___________ Date received: __________ Aliyah Shaliach: ___________________
Aliyah Representative: ___________________ Expected Aliyah Date: ___ /___/_____
This questionnaire is the basic document used for processing your Aliyah application. Please
provide all of the relevant details, so that we can give you prompt attention and accurate
information.
Please write clearly in block letters; put an x or check the appropriate places; if a question is not
applicable, please indicate this with "N/A".
Questions regarding your background are designed to provide an overall picture that will help
those assisting in your Aliyah preparation to anticipate your absorption needs. Some of this
information is also used for statistical purposes.
If you have any questions about filling in the application, please feel free to contact your local
Aliyah office or the Global Aliyah Center. You can find a list of toll free numbers at
www.jewishagency.org/English/
APPLICANT – PERSONAL DETAILS
Please write your name as it appears in your passport
Last name: First name:
Maiden name (if applicable): Former names (if applicable):
Date of birth: _____/______/_______ (dd/mm/yyyy)
Gender: Male Female
Marital status: single married separated divorced widowed partners
Religion: Jewish other (specify)
Mother’s full name: Mother’s maiden name:
Father’s full name: Father’s former name (if applicable):
Israeli ID number (if applicable):
Religious affiliation (check one or more): Orthodox Traditional Conservative
Progressive Reform Reconstructions Secular Other (specify)
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2. Country of birth: Nationality:
Additional nationality/ies (if applicable):
Passport # (including letters): Country issuing passport:
Country of residence (where you have lived in the year prior to your Aliyah):
Do you have a valid driving license? Yes No
(In the country where you have lived in the year prior to your Aliyah)
Occupation:
Education: High school some college Bachelor’s Degree Master’s Degree
PhD Yeshiva other (please specify)
Have you been a member of youth organizations/ movements?
If so, which one(s):
Have you ever been to Israel? Yes No
Have you ever been: Israeli citizen, temporary resident, permanent resident,
Oleh, or none of these? If yes, what year(s)?
Have you ever owned a home in Israel? Yes No
If yes, do you still own it? Yes No if no, when was it sold?
I have / have not spent more than 18 months in Israel in the past 3 years.
I have / have not spent more than 3 years in Israel in the past 7 years.
Have your parents ever lived in Israel? Yes No
Have your parents ever been Israeli citizens? Yes No
Have you served in the military? No Yes, IDF Yes, other (specify) ______________
HEBREW KNOWLEDGE- RANK YOUR KNOWLEDGE FROM 0 TO 5, WITH 0 AS NONE, 5 AS FLUENT
Speaking reading writing
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3. I WOULD LIKE TO APPLY FOR A VISA FOR:
Immigration (Oleh visa) Temporary residency (A1) Other
DECLARATION - please check one
I declare that I have not committed any criminal offense.
I declare that I have not committed any act directed against the Jewish people or the security of
the State of Israel.
There is no judicial warrant of arrest against me and I am not wanted by the police of any
country.
I confirm that the information on this questionnaire is full and accurate, and has been provided
in the awareness of the fact that it will serve as a basis for the consideration of my application.
I will notify the Aliyah office of any changes occurring prior to my Aliyah
___________________________________________
Signature of Applicant
The aliyah questionnaire was signed before ____________________________
Date:_____________________ ___________________________________
Signature of Jewish Agency Representative
Please attach a photo and a photo of spouse (if applicable)
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4. SPOUSE – PERSONAL DETAILS
Please write your name as it appears in your passport
Last name: Firs name:
Maiden name (if applicable): Former names (if applicable):
Date of birth: _____/______/_______ (dd/mm/yyyy)
Gender: Male Female
Marital status: single married separated divorced widowed partners
Religion: Jewish other (specify)
Mother’s full name: Mother’s maiden name:
Father’s full name: Father’s former name (if applicable):
Israeli ID number (if applicable):
Religious affiliation (check one or more): Orthodox Traditional Conservative
Progressive Reform Reconstructions Secular Other (specify)
Country of birth: Nationality:
Additional nationality/ies (if applicable):
Passport # (including letters): Country issuing passport:
Country of residence (where you have lived in the year prior to your Aliyah):
Do you have a valid driving license? Yes No
(in the country where you have lived in the year prior to your Aliyah)
Occupation:
Education: High school some college Bachelor’s Degree Master’s Degree
PhD Yeshiva other (please specify)
Have you been a member of youth organizations/ movements?
If so, which one(s):
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5. Have you ever been to Israel? Yes No
Have you ever been: Israeli citizen, temporary resident, permanent resident,
Oleh, or none of these? If yes, what year(s)?
Have you ever owned a home in Israel? Yes No
If yes, do you still own it? Yes No if no, when was it sold?
I have / have not spent more than 18 months in Israel in the past 3 years.
I have / have not spent more than 3 years in Israel in the past 7 years.
Have your parents ever lived in Israel? Yes No
Have your parents ever been Israeli citizens? Yes No
Have you served in the military? No Yes, IDF Yes, other (specify) ______________
HEBREW KNOWLEDGE- RANK YOUR KNOWLEDGE FROM 0 TO 5, WITH 0 AS NONE, 5 AS FLUENT
Speaking reading writing
I WOULD LIKE TO APPLY FOR A VISA FOR:
Immigration (Oleh visa) Temporary residency (A1) Other
DECLARATION – please check one
I declare that I have not committed any criminal offense.
I declare that I have not committed any act directed against the Jewish people or the security of
the State of Israel.
There is no judicial warrant of arrest against me and I am not wanted by the police of any
country.
I confirm that the information on this questionnaire is full and accurate, and has been provided
in the awareness of the fact that it will serve as a basis for the consideration of my application.
I will notify the Aliyah office of any changes occurring prior to my Aliyah
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6. ___________________________________________
Signature of Applicant
The aliyah questionairre was signed before ____________________________
Date:_____________________ ___________________________________
Signature of Jewish Agency Representative
CHILDREN - Please list all children under age 25. In addition, children over age 18 who will be
making Aliyah should open their own Aliyah file.
Is this child
Israeli ID
Date of birth Country of making
First and last name Gender Number
(dd/mm/yyyy) birth Aliyah with
(If applicable)
you?
M/F Yes / No
M/F Yes / No
M/F Yes / No
M/F Yes / No
M/F Yes / No
M/F Yes / No
M/F Yes / No
M/F Yes / No
M/F Yes / No
M/F Yes / No
M/F Yes / No
M/F Yes / No
Will the whole family be making Aliyah together? Yes No
Do any of the above minor children have a parent who will not be making Aliyah? Yes No
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7. CURRENT CONTACT DETAILS
Address:
City: State: Zip: Country:
Home Phone: Email:
Work phone: Spouse work phone:
Cell phone: Spouse cell phone:
PLANS UPON ARRIVAL IN ISRAEL
Expected Aliyah date:
Expected place of residence:
Address: ________________________________________________________
Rental Relatives Other (please specify) __________________
Phone number in Israel:
Are you interested in being matched with a volunteer family to assist you through your initial
absorption period? Yes No
Contact in Israel:
Name and relationship:
Address (include city):
Phone number:
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