The application is addressed "To the Keren Hayesod Association in Lvov" and states:
It is my wish to join your association as a (regular) (non-regular) member and I take it upon myself to pay the sum of 30.00 zloty per year. As an advance payment on that sum, I am presently paying the sum of 7.50 zloty and I will pay the outstanding balance in 3 installments of 7.50 (per month), (per quarter), (per half-year).The document was signed by Moses Wasserman, on his own behalf and for his son Leiser. Moses, who was born in 1868, was the son of Schaje and Chaje Wasserman. His marriage to Cirel Weidenfeld (daughter of Alter Mates Weidenfeld and Beila Wiesenthal) was registered in 1898, as was the birth of their son Leiser. Moses died in 1940. His wife Cirel, Leiser and his wife Regina and children Nusia and Miecio, and Mechel and his wife Pesia all perished in the Holocaust. [Skala yizkor book, pp. 94-95]
In the city of Skala, day 21, month 8, year 1938. Signature: Moses and Leiser Wasserman, Skala Podolska.
Document brought to our attention by Anatolie Didyk and posted courtesy of Routes to Roots Foundation, Inc., Secaucus, NJ. Source: Fond 335, Central State Historical Archives of Ukraine in Lviv