INDIVIDUAL MEMBERSHIP APPICATION
POLISH AMERICAN CONGRESS, Inc.

Date_______________________
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Last Name First Name Initial (s)
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Address (No., Street, City, State, Zip Code)
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Telephone Number (Home) Business Phone Position or Occupation
What Languages Do You Speak? ® English ® Polish ® Other
To what Polish-American organizations do you belong? (specify if you hold office) of
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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
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Print Name                                                             Print Name
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Address                                                                  Address
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The PAC State Division ® Recommends ® Does Not recommend this applicant
for individual membership in the PAC:
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Signature Title Date
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The PAC National Executive Committee ® Accepts ® Does Not accept this applicant
for individual membership in the PAC:
________________________________________ _________________________________________
Signature Title Date
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