Membership Application Form

EDMONTON NUMISMATIC SOCIETY
P.O.BOX 75024, RITCHIE P.O.
EDMONTON,  ALBERTA, CANADA
T6E 6K1

SURNAME _________________  FIRST NAME_______________
MAILING ADDRESS
STREET ________________    APT.#__________
CITY ______________ PROVINCE/STATE _______________ 
COUNTRY______________    POSTAL CODE ____________
EMAIL ADDRESS _____________
HOME PHONE NO. _____________ 
WORK PHONE NO. _____________
FAX NO.________________________

MEMBERSHIP REQUESTED

Canadian Residents (in Canadian funds):
REGULAR ($15.00)___ FAMILY ($15.00)____ 
JUNIOR (16 AND UNDER) ($5.00) _____

United States Residents (in US funds):
REGULAR ($20.00)___ FAMILY ($20.00)____ 
JUNIOR (16 AND UNDER) ($10.00) _____

Foreign Residents -non-US & non-Canadian addresses (in US funds):
REGULAR ($40.00)___ FAMILY ($40.00)____ 
JUNIOR (16 AND UNDER) ($20.00) _____

NUMISMATIC INTERESTS

TYPE OF INTERESTS (Canadian Decimal, Ancient, Paper etc.)
__________________________________________________________
__________________________________________________________
__________________________________________________________

LENGTH OF TIME COLLECTING __________________________________________________________

REFERENCES  (Names of club members known to you)
__________________________________________________________
__________________________________________________________

DATE OF APPLICATION _________SIGNED ___________________

FOR ONE (1) CALENDAR YEAR MEMBERSHIP IN THE EDMONTON NUMISMATIC SOCIETY (JAN. TO DEC.) (HALF PRICE IF JOINING FROM SEPTEMBER TO DECEMBER)

(Subject to approval by the Membership, an official receipt and membership card will be issued. )

FOR MORE INFORMATION PLEASE PHONE  (780) 433-7288 AND ASK FOR RAY

The Edmonton Numismatic Society meets on the second Wednesday of the month at the Royal Alberta Museum, 12845 - 102 AVE., EDMONTON, ALBERTA, CANADA.