Polish American Cultural Center Museum “Memorial Honor Roll”

308 Walnut Street • Philadelphia, PA 19106 • (215) 922-1700

PolishAmericanCenter.com

Time to Remember Reply Form

Please choose one of the following categories:

Categories of Memorial listings: $25.00 donation includes: 1. One line listing in the Memorial Honor Roll which will be published in the next edition of the Polish American News with name of deceased and name of donor.

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$50.00 donation includes: 1. One line listing in the Memorial Honor Roll which will be published in the next edition of the Polish American News with name of deceased and name of donor. 2. One line listing on the 2010 Museum’s Internet Memorial Honor Roll with name of deceased and name of donor.

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$100.00 donation includes: 1. One line listing in the Memorial Honor Roll which will be published in the next edition of the Polish American News with name of deceased and name of donor. 2. One line listing on the 2010 Museum’s Internet Memorial Honor Roll with name of deceased and name of donor. 3. The Internet listing will open as a 5 inch wide X 2 inch high memorial ad with the deceased individual being honored and the name of the donor.

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$250.00 donation includes: 1. One line listing in the Memorial Honor Roll which will be published in the next edition of the Polish American News with name of deceased and name of donor. 2. One line listing on the 2010 Museum’s Internet Memorial Honor Roll with name of deceased and name of donor. 3. The Internet listing will open as a 5 inch X 5 inch memorial ad with a 1.5 inch X 1.5 inch photo of the deceased individual(s) being honored along with the name of the donor. Kindly enclose photo along with your donation. $350.00 donation includes: 1. One line listing in the Memorial Honor Roll which will be published in the next edition of the Polish American News with name of deceased and name of donor. 2. One line listing on the 2010 Museum’s Internet Memorial Honor Roll with name of deceased and name of donor. 3. The Internet listing will open as a 5 inch X 5 inch memorial ad with a 1.5 inch X 1.5 inch photo of the deceased individual(s) being honored along with the name of the donor. Kindly enclose photo along with your donation. 4. 5 inch X 2 inch memorial ad will be printed in the Polish American News.

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In support of the 2010 Time to Remember Campaign, I am requesting the following name(s) to be listed on the Memorial Honor Roll:

Names will be listed in alphabetical order

List the following on the Memorial list:

Name(s) (print full name)	Year Deceased	Offered by	Donation
			$
			$
			$
			$
			$
			$
			$
Total Enclosed			$

Make your check payable to and mail to:

Polish American Cultural Center	Telephone: (215) 922-1700
308 Walnut Street
Philadelphia, PA 19106	Donations are tax deductible.

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Donor Name
Address
City	State	Zip
Telephone	Email

Kindly print this form and return with your donation. All donations will be acknowledged in writing. If you have any questions, call our office at the telephone number listed above.