Society of Inkwell Collectors Membership Application |
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| Date: _______________________________ | please print all information |
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| Name: __________________________________________________________________________________ | ||
| Title (circle one): Mr. Mrs. Ms. Dr. other: ________ | ||
| Address (circle one): Home or Business (Business name: ____________________________________________) | ||
| ________________________________________________________________________________________ | ||
| ________________________________________________________________________________________ | ||
| City: ____________________________________ | State or Region: _______________________________ | |
| Zip code (postal code): ______________________ | Country: _____________________________________ | |
| Home Phone: ______________________________ | Home Fax: ___________________________________ | |
| Home e-mail: ______________________________ | Home Cell: ___________________________________ | |
| Business Phone: ____________________________ | Business Fax: _________________________________ | |
| Business e-mail: ____________________________ | Business Cell: _________________________________ | |
| Are you a dealer? Please include your speciality(ies): ________________________________________________ | ||
| ________________________________________________________________________________________ | ||
| Referred by, or how you heard of the SOIC: ______________________________________________________ | ||
| ________________________________________________________________________________________ | ||
| Areas of interest in collecting inkwells (use the back if you need more space): ______________________________ | ||
| ________________________________________________________________________________________ | ||
| S | ||
| U.S. Address (circle one): | $45 for 1 year | $80 for 2 years |
| Non-U.S. Address (circle one): | $55 for 1 year | $100 for 2 years |
| S | ||
| Credit Card | ||
| (circle one) Visa or Mastercard (none other accepted) | Number: _____________________________________ | |
| Name on card: ________________________________ | Expiration date: ________________________________ | |
| Billing address: ____________________________________________________________________________ | ||
| Check | ||
| Make check or money order (in U.S. dollars) payable to: | Society of Inkwell Collectors | |
| Mail to: | ||
| SOIC - Membership | ||
| 2045 E CR 900 N | ||
| Camargo, IL 61919 USA | ||