Marie Sklodowska-Curie Professional Women's Association, Inc.

c/o Polish National Alliance of Brooklyn, U.S.A., 155 Noble Street, P.O. Box 22-9006, Brooklyn, NY 11222-9006

(718) 389-4704/5 . . . . . . . . Fax (718) 383-8517

www.curiewomen.org

Application for Membership

Please print clearly or type

Name____________________________________________________

Home Address______________________________________________

E-mail Address_______________________________________________

Home Telephone__________________ Place of Birth________________

Business/Profession__________________________________________

Currently Engaged___________ Aspiring__________ Retired_________

Business Address____________________________________________

Business Telephone______________________Fax_________________

How did you hear about this organization?________________________

Education_________________________________________________

_________________________________________________________

Hobbies and Interests________________________________________

Date of Birth_______________________________________________

(Optional for use in determining demographics and planning programs and activities)

Other affiliations____________________________________________

_________________________________________________________

Acknowledgement: I am in agreement with the objectives, ideals and purposes of the Association and agree to abide by its Constitution and ByLaws.

_________________________ . . . . . . . . . . . . . . . . _________________________

Member's Signature . . . . . . . . . . . . . . . . . . . . . . . . . Today's Date

____________________________________________________________________

FOR OFFICE USE ONLY

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