Museum Membership Form

MEMBERSHIP APPLICATION

Regular Member ($25.00 annually per person)
Patron ($50.00 annually)
Benefactor ($100.00 annually)
Institutional Member ($250.00 annually)
Life Member ($2,500.00)

Please check the appropriate category

Regular $25/yr Patron $50/yr Benefactor $100/yr
Institutional $250/yr Life $2,500

Name ______________________________________________________

Address _____________________________________________________

City ______________________________ State ______ Zip ____________

Phone (_____)______________________

AMOUNT ENCLOSED _______________

Please make check payable to:	THE POLISH MUSEUM OF AMERICA
Please send to:	PMA Membership
	984 North Milwaukee Avenue
	Chicago, Illinois 60642

Tel (773)384-3352 Fax (773)384-3799
501(c)3 under IRS Code

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