“Service Above Self”

UNICO  NATIONAL
THE LARGEST ITALIAN AMERICAN SERVICE ORGANIZATION IN THE UNITED STATES
FAIRFIELD COMMONS, 271 US HWY 46 WEST, SUITE F-103, FAIRFIELD, NEW JERSEY, 07004
PHONE: (973) 808-0035, FAX (973) 808-0043, E-mail: uniconational@unico.org

MEMBERSHIP APPLICATION
(please print or type clearly)		   Regular

 Date Submitted:
 Date Approved:
 Chapter Secretary:
Signature:
 Initial Fee Attached:

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Passaic Valley Chapter
 Annual Dues
Fiscal Period: July to June
 Chapter Name:       PASSAIC VALLEY             District (State & Number) :  NJ  IV
 Applicant’s First Name:    Last Name:
 Home Address:   City:
 State:          Zip Code:          Home Phone:
 Cell Phone:     Email Address:
 Date of Birth:      Are you a U.S. Citizen?    YES    NO       Place of Birth:
 Proof of Italian Heritage or Ancestry  (ie: Maiden Name, Grandparents Name):     Date Naturalized?  :xx/xx/xxxx
 Occupation?     Employer:      Business Phone:

List Involvement in Community/Organizations or Offices Held (please include which offices held and years)

REFERENCES (Please list two)
 Name:  Name:
 Address:  Address:
 City:   Phone:  City:     Phone:

SPONSORS

Do you understand that UNICO National is a Service Club of Americans of Italian Heritage dedicated to “Service Above Self”?
 YES   NO

I hereby apply for membership and agree to abide by the UNICO National Constitution and By-Laws of UNICO National and this Chapter:

Applicant Signature:   ______________________________________   Date: _________________

 Clicking this check box    indicates your acceptance to this online application, the information you entered is 100% correct and your IP address
 will be your electronic signature.  This application will be submitted with your payment and you will be contacted within 4 business days or sooner

     REV 10/2015