Name:

Address:

Phone Number:

Email:

Birth Date and Place:

Occupation:

Other organizations to which you belong:



Collecting Interests:

Exchange Interests:

Describe your bookplate, any special symbolism, the artist, designer, etc. Other comments.

Please remember to send two prints of your personal bookplate, if available.

Dues Enclosed: $ Date:

Signature: (For those mailing their application, please sign before mailing.)

If Paying by Credit Card...

Check one: Master Card Visa

Card Number: Expiration Date: