Polish American Congress

Polish American Congress, Inc
INDIVIDUAL MEMBERSHIP APPLICATION

Mr. Mrs. Ms. Miss Dr.

Last Name First Name M. I.
Address Residence Phone
Addr. Line 2 Business Phone
City State Zip Fax
Occupation E-Mail


American Citizen		 By birth
Naturalized
   Languages Spoken: English Polish
Permanent Resident     Other

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Signature of Applicant

As required by the PAC Bylaws, membership of the above applicant is recommended by:

_________________________________________________
Signature		 __________
Date		 _______________________________________________
Signature		 ___________
Date

____________________________________________________________
Print Name
________________________________________________________________
Print Name

____________________________________________________________
Address
________________________________________________________________
Address

_______________________________________________
 _________________________________________________
The PAC State Division _____ recommends
  _____ does not recommend

this applicant for Individual Membership in the
Polish American Congress

Signature________________________________________________

Print Name____________________________________________ Date__________
Title _____________________________________
The PAC National Office _____ accepts
  _____ does not accept

this applicant as an Individual Member of the
Polish American Congress

Signature__________________________________________________________

Print Name___________________________________________ Date__________
Title_____________________________________________

For address of State Division, see State Division Directory