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 __________.
You may pay by sending a US Dollar check to Jeff Modesitt at the address above
or via Paypal to JEFFMGBCC@Q.COM
If you wish to pay with your Visa/Mastercard,
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).
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| Pre-stamp Era | . _____ | |||
| Queen Victoria - Engraved | . _____ | . _____ | . _____ | . _____ |
| Queen Victoria - Embossed | . _____ | . _____ | . _____ | . _____ |
| Queen Victoria - Surface Printed | . _____ | . _____ | . _____ | . _____ |
| King Edward VII | . _____ | . _____ | . _____ | . _____ |
| King George V | . _____ | . _____ | . _____ | . _____ |
| King Edward VIII | . _____ | . _____ | . _____ | . _____ |
| King George VI | . _____ | . _____ | . _____ | . _____ |
| Queen Elizabeth II - Commems | . _____ | . _____ | . _____ | . _____ |
| Queen Elizabeth II - Wildings | . _____ | . _____ | . _____ | . _____ |
| Queen Elizabeth II - Machins | . _____ | . _____ | . _____ | . _____ |
| Queen Elizabeth II - Regionals/Other definitives | . _____ | . _____ | . _____ | . _____ |
| ___ Armed Forces | ___ Machine Marks | ___ Postal History | ___ Underprints |
| ___ Air Mail | ___ Newspaper Stamps | ___ Parcel Post | ___ Ship/Maritime |
| ___ Booklets (Eras _____________) | ___ Numeral Cancels | ___ Telephone/Telegraph | ___ Channel Islands |
| ___ Railway Stamps | ___ Exhibitions | ___ Perfins | ___ Revenues |
| ___ Other |
GBCC Office Use
| Date Received: | Membership Number: | Amount Paid: |
| Sample Sent: | Chronicles Sent: |