Application For Membership in the Illinois Numismatic Association.

Date : ____________________

Mr.
Mrs.
Miss. _____________________________________________________________

Name, Please Print

Address: ___________________________________________________________

City: ____________________ State: _________ Zip Code + Four: _______________

Area Code Phone: _____________________ Birth Date(if under 18): _____________

email: ______________________________________________________

Occupation: _______________________________________________________

Numismatic Specialty: ______________________________________________

Signature of Applicant: ______________________________________________

Local coin club of which you below: ____________________________________

Club Application:___________    Individual Application _____________

ANNUAL DUES: Adult: $8.00       JUNIOR: (Under 16) $2.00

Complete form, with proper amount of Money (money order or check), mail to :

ILNA c/o Michael Doran, PO Box 30, Greenup, IL 62428-0030