INDIVIDUAL MEMBERSHIP APPICATION
POLISH AMERICAN CONGRESS, Inc.
Date________________
______________________________________________________________________________________
Last Name First Name Initial (s)
__________________________________________________________________________________________________
Address (No., Street, City, State, Zip Code)
__________________________________________________________________________________________________
Telephone Number (Home) Business Phone Position or Occupation
What Languages Do You Speak? ® English ® Polish ® Other
To T what Polish-American organizations do you belong? (specify if you hold office) of
__________________________________________________________________________________________________
__________________________________________________________________________________________________
______________________________________________________________________________________
CITIZENSHIP:
® American Citizen ® By Birth ® By Naturalization - Month and Year ____________________________________________
® Permanent Resident Date of Arrival in the United States - Month and Year _______________________________________
Applicant Signature: _______________________________________ Date _________________________
As required by the PAC By-Laws, membership of above applicant is recommended by:
1. _____________________________________________________ 2. _________________________________________
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 PAC:
________________________________________ ________________________________________________ _________
Signature Title Date
______________________________________________________________________________________
The PAC National Executive Committee ® Accepts ® Does Not accept this applicant for individual membership in the PAC:
________________________________________ ________________________________________________ _________
Signature Title Date
______________________________________________________________________________________
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