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
|
__________________________________________ |
__________________________________________ Website |
Date of Birth __ __ - __ __ - __ __ Month Day Year |
_____________________________________ Occupation |
_________________________________________________ Major Stamp Collecting Interests |
________________________________________________________________ Visa, MasterCard, or other Commercial Reference |
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Account Number |
__ __ - __ __
Expiration Date |
_________________________________________________________________________________________________ Mailing Address for Commercial Reference (not necessary for Visa or MasterCard accounts) |
________________________________________________ Signature of Applicant |
________________________________________________ Signature Parent/Guardian (required for applicants under age 18) |
www. philately.com / James R. D. Yeaw_______________ Name of Proposer |
$__________ |
[ ] Check |
[ ] Money Order |
[ ] Visa |
[ ] MasterCard |
___________________________________
Signature of Cardholder |