NAME: _____________________________________________________ DATE: ______________

Mr. ____ Mrs. ____ Miss ____ Ms. _____ Other _____

MAILING ADDRESS: ____________________________________________ AGE (if under 18): _______

________________________________________________________________________________

CITY: __________________________________ STATE: __________ ZIP+4/POSTCODE: ___________

COUNTRY:___________________________________________________________

TELEPHONE: Day ________________________Residence _________________________

EMAIL ADDRESS: ___________________________________________________________

May we send you an occasional email with GBCC news and events? Yes ______ No ______

(Email addresses are never given out to other people or organizations)

DUES
North America: US$25 per year
Elsewhere: US$35 per year
You may pay for multiple years. Number of years paid for __________.

If you wish to pay with your Visa/Mastercard rather than US Dollar check or money order, please provide the all following information:

Name on card (please print):___________________________________________________

_____Visa or ______ Mastercard

Card Number:  __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __     Expiration Date (MM/YY):___________

Security Code:  __ __ __  (3 digit code on the back of the card)

BILLING ADDRESS (if different from mailing address): ____________________________________________

________________________________________________________________________________

CITY: ____________________________ STATE: __________ ZIP+4/POSTCODE: ___________

COUNTRY:___________________________________________________________

Amount to be charged: $_______US Dollars

Signature: _____________________________________________________________________

HOW DID YOU LEARN ABOUT GBCC? __________________________________________

PHILATELIC ORGANIZATIONS:   APS # _________________

    OTHERS: _______________________________________________________________

PHILATELIC INTERESTS (other than GB): _________________________________________________________

GREAT BRITAIN PHILATELIC INTERESTS

Please indicate a major interest with an XX and a minor interest with an X (mark all that apply).