Print this page and mail to the address below.

Application  for  Membership

Mail to:  Executive  Secretary,  Larry Ballantyne, P. O. Box  6634,  Katy,  TX   77491-6634

I hereby apply for membership in the United States Stamp Society, and have enclosed payment for my initiation fee, dues, and a subscription to The United States Specialist based on the remittance schedule below.  I understand that the full amount of my remittance will be returned to me if my application is not accepted.

Name _____________________________________________  Date of Birth _______________

Address _____________________________________________________________________

City _________________________________ State __________ Zip+4 ________________

References

Note: References are not required of current members of the Philatelic Society or the American Stamp Dealers Association.  Only a membership number is needed.  Others should provide a full name and address of a personal and a philatelic reference.

APS No. _______________                                                   ASDA No. _______________

Personal Reference ____________________________________________________________

Philatelic Reference ___________________________________________________________

Signature of Applicant _________________________________ Date ___________________

Signature of Sponsor                   Roland  Austin                             BIA#              13032        

Remittance Schedule

Amounts include dues, initiation fee, and a subscription to The United States Specialist.  Postage prepaid for U.S. addresses only; North America add $3.00;  Others add $7.00 in US funds.  Make all checks payable to the U.S.S.S.

Jan.-Feb.-Mar.     $25.00

Apr.-May-June     $20.00

July-Aug.-Sept.    $15.00                                            Amount  Enclosed ________________

Oct.-Nov.-Dec.     $30.00  (* Includes 12 months of following year)

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