This is the "SHUL V3" template. It should be called in the following format:
{{SHUL V3
|NAME OF RABBI:=
|NUSACH=
|ADDRESS:=
|OFFICIAL CITY NAME:=
|CITY:=
|STATE:=
|ZIPCODE:=
|COUNTRY:=
|PHONE NUMBER:=
|WEB PAGE=
|EMAIL ADDRESS=
}}
Edit the page to see the template text.