Polish Society of Houston
Dba Ognisko Polskie
13340 Balcrest Dr.
Houston TX 77077

telephone: 832-912-7007 (Teresa Laskosz)
ognisko-psh@email.com

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MEMBERSHIP FORM

Please enroll me to The Polish Society of Houston, Inc., Ognisko Polskie.

Name: ______________________________________________________________________________

Last First Middle In.

Name: ________________________________________________________________________

Last First Middle In.

Address: ________________________________________________________________________

Street

______________________________________________________________________________

City State ZIP Code

______________________________________________________

Phone Number

 _________________________________________________

E-mail

Annual membership fee for the year 2006, Family $20 ______ Individual $15______

I am enclosing donation of: $____________

___________________________________ __________________________

Signature Date

 NOTE: For Family membership, please include both spouses’ names.