To:	Board of the Polish Fulbright Alumni Association correspondence adress: ul. Wróblewskiego 15 93-590 Łódź Poland E-mail: abramczy@mitr.p.lodz.pl
From:
Date:
Ref:	Membership in the Polish Fulbright Alumni Association

FIRST NAME:	_____________________________________________________
LAST NAME:	_____________________________________________________
ACADEMIC DEGREE:	_____________________________________________________
FIELD:	_____________________________________________________
DATE OF THE FULBRIGHT GRANT:	_____________________________________________________
US INSTITUTION:	_____________________________________________________
ACADEMIC YEAR:	_____________________________________________________
HOME ADDRESS:	_____________________________________________________
PHONE:	_____________________________________________________
PRESENT HOME INSTITUTION:	_____________________________________________________
POSITION:	_____________________________________________________
WORK ADDRESS:	_____________________________________________________
PHONE:	_____________________________________________________
FAX:	_____________________________________________________
E-MAIL:	_____________________________________________________
SPOUSE'S NAME:	_____________________________________________________

I am willing to join the Polish Fulbright Alumni Association.


___________________________________ Signature