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

                       ______________________________________________________________________________________