Albanian American Civic League

(Please print all information)

NAME_____________________________________________________________________
                  (first)                       (last)                          (spouse’s first name)

HOME ADDRESS______________________________________APT. #_______________

CITY:___________________________________ STATE:________ ZIP CODE:_________

HOME PHONE: ________________________WORK PHONE:______________________

E-MAIL: ______________________________ CELL PHONE:_______________________

CONTRIBUTION: $___________________

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Membership Classification/Suggested Contribution:

Regular/Individual                                           $100      _______________________________
                                                                                                             (occupation)

Family                                                               $250      _______________________________
                                                                                           (names of children for their cards)

Student                                                              $25       _______________________________
                                                                                                        (name of school)

Foreign (non-U.S. national)                             *            _______________________________
                                                                                                             (country)
                                                                                              *Amount that you can afford