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 |
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) |
| ________________________________________________ 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 |