Love Indonesia Philately

Membership Referral from www.prangko.com

See instructions regarding dues amounts, payment submittal, etc. on web page

Application for Association, Group or Society _________________________________________

Amt of Dues or Fees Submitted _______________ Currency of payment ___________________

Method of payment___________________  Previous Member?____ Number, if known_________


Applying For: [   ]Regular Member [   ]Life Member [   ]Associate Member

_____________
Mr., Mrs., Other
________________________________
First Name
_________
Middle Initial
____________________________________
Last Name
_______________________________________________________________________________________________
Address
_________________________________________________________ 
City
_________ 
State
_________________________
ZIP Code
__ __ __ - __ __ - __ __ __ __
Social Security Number
        __ __ __ - __ __ __ - __ __ __ __
Daytime Phone
        __ __ __ - __ __ __ - __ __ __ __
Fax
__________________________________________ 
E-mail
__________________________________________ 
Website
Date of Birth __ __ - __ __ - __ __
                     Month    Day      Year
_____________________________________
Occupation
_________________________________________________
Major Stamp Collecting Interests
I authorize you to verify the commercial reference listed below, and, if necessary, to obtain a current credit report upon receipt of this application. I agree to abide by the society's Code of Ethics and agree to be bound by all rules and regulations of the Society and its bylaws. I understand notice of applications for membership may be published in the society newsletter. Please provide a current Visa or MasterCard account number and expiration date or the name and address of another commercial reference (a company or stamp dealer with whom you do business, or your employer, etc.)
________________________________________________________________
Visa, MasterCard, or other Commercial Reference
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Account Number
__ __ - __ __
Expiration Date
_________________________________________________________________________________________________
Mailing Address for Commercial Reference (not necessary for Visa or MasterCard accounts)
[   ] Check here if you do not want the Society to provide your name to firms with philatelic offers deemed of value to the membership.
________________________________________________
Signature of Applicant
________________________________________________
Signature Parent/Guardian
(required for applicants under age 18)
www. philately.com / James R. D. Yeaw_______________
Name of Proposer

Payable in currency. Checks must be drawn on a bank acceptable to the organization. If acceptable, you may provide a Visa or MasterCard account number. Enter the amount to charge and sign below.
$__________
 
[   ] Check
 
[   ] Money Order
 
[   ] Visa
 
[   ] MasterCard
 
___________________________________
Signature of Cardholder
 
Back to Love Indonesia Philately