PCCC Membership Form

POLISH CANADIAN CULTURAL CLUB P.O. BOX 3323 REGINA, SK S4P 3H1

pccc@sasktel.net https://www.facebook.com/Polish-Canadian-Cultural-Club-of-Regina-Saskatchewan-Canada-1282948365192866
MEMBERSHIP APPLICATION FORM

FORMULARZ DO CZŁONKOSTWA
Date*

MonthDayYear
Date
Annual Membership/ Roczne członkowstwo*

Single Person/ Indywidualne $10.00Family/Rodziny $20.00
Payment Type*
Name/Imie i nazwisko*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone/ Telefon Number *
Please enter a valid phone number.
Cell/Komorka Number
Please enter a valid phone number.
Email*
example@example.com
Langues/Język*

English/AngielskiPolish/PolskOther/Inne
Name of spouse/partner/second member Imie i nazwisko malzonek(ka)
Phone/Telefon
Cell/Komorka
Email
example@example.com
Langues/Język

English/AngielskiPolish/PolskOther/Inne
Names of children/Imiona dzieci (18 and under/18 i mniej)
YOB/Rok urodzenia
Year
Names of children/Imiona dzieci (18 and under/18 i mniej)
YOB/Rok urodzenia
Year
Names of children/Imiona dzieci (18 and under/18 i mniej)
YOB/Rok urodzenia
Year
Names of children/Imiona dzieci (18 and under/18 i mniej)
YOB/Rok urodzenia
Year
Names of children/Imiona dzieci (18 and under/18 i mniej)
YOB/Rok urodzenia
Year
Signature/Podpis*

Clear
Should be Empty:

POLISH CANADIAN CULTURAL CLUB P.O. BOX 3323 REGINA, SK S4P 3H1