WNVC Membership Form

distributed by friends of Poland in the Washington metropolitan area


 
First Name and Middle Name Initial
    
Last Name
  
Address Line 1
  
Address Line 2
  
Address Line 3
  
City, State and ZIP
  
Telephone
  
E-mail
  
Favorite Program
 news from Poland (as recent as possible) and other Poland-related television programs
Other Favorite Programs
  
I realize that the membership is free, but I want to make a donation
 [___] $35 Associate (czlonek stowarzyszony)

[___] $60 Friend (przyjaciel stacji WNVC)

[___] $90 Diplomat

[___] $120 Ambassador
Payment Method
 [___] Enclosed is my check.

[___] Visa

[___] MasterCard
My card number is
  
Expiration Date
  
Signature
  

Please make your check payable to WNVC.


 
Please mail this form with payment to
 
 
 

or fax it to

 WNVC
Attn: Membership Department
8101A Lee Highway
Falls Church, VA 22042

(703) 849-9796

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For general information about WNVC
 please write to WNVC, 8101A Lee Highway, Falls Church, VA 22042,

visit WNVC's website

or call (703) 698-9682.