INSTRUCTIONS: It's easy to start your membership in the Old Certificates Collectors' Club! Please print this page, fill out the form, then send it with your payment to our address at the bottom of the page.

Your Name:
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Address:
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City:
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State/Province:
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Zip/Postal Code:
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Country:
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Home Telephone:
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Work Telephone:
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E-mail Address:
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Referred by:
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Field(s) of Interest
___ Automobile
___ Aviation
___ Banking/Finance
___ Communication
___ Food/Beverage
___ Industrial
___ International
___ Leisure
___ Mining
___ Oil
___ Railroad
___ Shipping
___ Signature
___ Utilities
___ Others

Wish List Item(s)
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Back Issues: $5.00/year

___ 1994 (3 issues)
___ 1995 (3 issues)
___ 1996 (4 issues)
___ 1997 (4 issues)
___ 1998 (4 issues)
___ 1999 (4 issues)

Fees: U.S. $15.00/year made payable to Stock Search International Inc.

___ 12-month Club Membership: U.S. $15.00
___ Back Issues: U.S. $5.00 per year
___ TOTAL PAID

Credit Card Information
____ Visa
____ Mastercard

Credit Card Number:
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Expiration Date:
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Cardholder Signature:
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