Enclosed is my 2009 PAC Membership Fee of:

$60 (organization)

$30 (individual)

$10 (student)

(Check appropriate fee).

Please fill it up (PRINT OUT):

First and Last Name: __________________________________________________________

Current Address: _______________________________________________________________

                             _______________________________________________________________

City, State, Zip: _________________________________________________________________

Home Telephone# __________________________________

Other (cell) Telephone# ____________________________  

E-Mail Address: _________________________________________________________________

Please make checks payable to:

Polish American Congress  NJDiv.

and send your checks to:

Polish American Congress  New Jersey Division,

177 Broadway, Clark, NJ 07066