New Membership New MembershipRenewal RenewalAssigned ID NumberID Number (Leave blank if this is a new membership)Name (First and Last)(Required) First Last DOB(Required) MM slash DD slash YYYY Date(Required) MM slash DD slash YYYY Phone(Required)Mailing Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email(Required) ANA (American Numismatics Association) Member?(Required) Yes No # Emergency Contact Information:(Required) First Last Phone Number(Required)Has the member information provided above been updated?Untitled Yes No Type of Membership: (1, 2 or 3 see below*)Number(If #3 selected, provide Family Member Info below) *The annual membership dues shall be: 1. Individual Members - $20 per year 2. Young Numismatists (YNs) - $5 per year (age 17 Years old or younger) (Separate application for each YN applicant required, unless registering under Family Membership) 3. .Family Membership - $25 per year for first two members and $5 for each additional member. Please Select number of family members:Untitled 2 members = $25 Untitled 3 members = $30 Untitled 4 members = $35 Untitled 5 members = $40 (Note: Special rules apply for Adult family members: They must reside in the same home as primary member and are limited to a maximum of 3 adults; Elderly parents/grandparents may live separately, if primary member is responsible for their care. If more than 5 members contact ACC)Family Member Names (First and Last Names) First Last Family Member Names (First and Last Names) First Last Family Member Names (First and Last Names) First Last Family Member Names (First and Last Names) First Last Family Member Names (First and Last Names) First Last Their E-mail Addresses Their E-mail Addresses Their E-mail Addresses Have you attended our Coin Shows? Yes No How did you find out about the club? Club Use Only Membership Number Membership Year Date Received MM slash DD slash YYYY Dues Received by Card Issued Mailed Hand Delivered Submit application electronically and Pay online ($1 processing fee will be added): NameThis field is for validation purposes and should be left unchanged.
