Polish American Cultural Center Museum
308 Walnut Street - Philadelphia, PA 19106 - (215) 922-1700

Membership/Donation Form
(Kindly return this form with your reply)

In support of the Polish American Cultural Center Museum Exhibit Hall, I am enclosing my membership/donation.

Date ________________
_______
General annual membership $50.00
_______
Polish Eagle annual Membership $75.00
_______
Polish Patriot annual membership $100.00
_______
Exhibit Hall Patron. Includes annual membership $150.00
_______
Exhibit Hall Sponsor. Includes annual membership $250.00
(Includes Listing on the Sponsors Directory)
Total enclosed
 $__________________
Please make check payable to the Polish American Cultural Center

Or charge my: ____ Visa ____ American Express ____ Discover ____ Master Card
Total credit card amount $ _____________________ Card # ___________________________________
CVV Code# _____________ Expiration Date ____________Signature____________________________
Contributions are tax deductible to the extent permitted by law. We are grateful for your support.
Your reply will be acknowledged by mail with a membership card.

Membership Mailing Information (Please print or type your information here.)

Name _______________________________________________________

Address _____________________________________________________

City ________________________ State ______________ Zip __________

Telephone: Area Code (_______) ________________________________

E-mail ______________________________________________________

Mail this form to:
Polish American Cultural Center
308 Walnut Street
Philadelphia, PA 19106