Membership Application

 First name, title _________________________         Last Name __________________________

Street, and house name or no. ………………………………………………

City _______________       Postal Code _____________

State/Region _________________ Country _________________

Telephone (home) ………………………………(office) ……………………...

Email __________________

Special Interests

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Member of the following Philatelic/ postal history Societies:

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 (signed) ……………………………………..

Please INCLUDE GUMMED SELF-ADDRESSED LABELS if possible.