Membership Information

Individual Membership Application Form

Please, enter your e-mail:

First Name:	Last Name:

Address:	Tel. No.:

Date of Birth:	Place of Birth:

Occupation:	Citizenship:

Place of Employment:

Spouse's First name, Maiden Name and Birth Place:

Children's name(s), Age(s), Occupation(s):

I hereby apply for membership to the Ukrinian Institute of America as indicated below:
Member for life $1000
Membership/Initiation Fee is payable in full upon submission of Application with the exception of Member for life fee, which may be paid accordinng to either of the following plans: Plan A: Payable in full with submission of Application Plan B: 25% payable with submission of Application; balance payable with three years with 25% minimum annual payment Please note that depending on your membership choice, you would need to submit your payment to the Ukrainian Institute of America separately from this application. Detailed instructions where to send the payment or how to pay online will be sent to your confirmation e-mail
Membership/initiation Fee is tax deductible. Tax identification number: 13-1832391
Give names and addresses of three persons (at least one of whom is a UIA member) who you know:
1.
2.
3.