Medal Society of Ireland

Medal Society of Ireland

Membership Application Form

TITLE
(Mr/Ms/Mrs/Miss or Rank etc.)

NAME
(First Name(s))
(Last Name)

ADDRESS

COLLECTING INTERESTS

Please indicate if you are a

	Collector
	Dealer
	(Tick all that apply)

Do you wish to have your Address published in the Society's Journal

	Yes
	No
	(Select choice)

SIGNATURE

DATE
/ /

Subscription enclosed

Currency	Amount	Format

	(Enter Amount)

Annual subscription is payable on application and thereafter on 1^ST of January each year.

Please forward a printed copy of the completed application form together with subscription payments to the Membership Secretary -

Patrick J. Casey
1 The Hill ,
Stillorgan,
Co. Dublin.
IRELAND.

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