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The Indiana State Numismatic Association MEMBERSHIP APPLICATION FORM

NAME (PRINT): Mr/Ms/Miss__________________________________________

ADDRESS:_________________________________________________________

CITY: ______________________________________________

STATE or PROVINCE: ______________________________ ZIP CODE: ________________

COUNTRY: _______________________________

PHONE NUMBER: (______) _____________________________

E-MAIL ADDRESS: _______________________@ __________________________

BIRTHDATE (if under 18): ___________________________

OCCUPATION:__________________________________________

NUMISMATIC INTERESTS: _____________________________________________________

PREVIOUS ISNA MEMBER?: YES_______NO________IF YES, PREVIOUS MEMBERSHIP #____________________________

LOCAL CLUB AFFILIATION:____________________________________________________

IS THIS APPLICATION FOR A: CLUB :_______OR INDIVIDUAL ________

ANNUAL MEMBERSHIP DUES: REGULAR $10, CLUB $10, JUNIOR (Under 18) $2.50. INTERNATIONAL $20. LIFETIME $200.

Membership begins January 1 and ends December 31 of the same year. All memberships are subject to the Constitution and By-Laws of The Indiana State Numismatic Association.

SIGNATURE*: ________________________________________
*If under 18, Parent or Guardian must sign.

Print out this form, fill in the blanks and enclose with correct amount of money (check or money order) and mail to: ISNA, % Joyce Fischer, 1123 W. 8th Street, Anderson, IN 46016-2616, USA

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