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-
MEMBERSHIP APPLICATION FORM
FORMULARZ DO CZŁONKOSTWA
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Annual Membership/ Roczne członkowstwo
*
Single Person/ Indywidualne $10.00
Family/Rodziny $20.00
Payment Type
*
Please Select
etransfer - info@pcccregina.com
Cheque - P.O. Box 3323 Station Main
Regina, SK S4P 3H1
Cash/Cheque - In person
Paid Via Polonia Dance Fees
Name/Imie i nazwisko
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone/ Telefon Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Cell/Komorka Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Langues/Język
*
English/Angielski
Polish/Polsk
Other/Inne
Name of spouse/partner/second member Imie i nazwisko malzonek(ka)
Phone/Telefon
Cell/Komorka
Email
example@example.com
Langues/Język
English/Angielski
Polish/Polsk
Other/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
*
Submit
Should be Empty: