Antique Telephone Collectors Association P.O. Box 1252 McPherson, Kansas 67460 Membership Form

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Online Registration:

Member Information: (To be included on membership list) Name: Address: City: State: Select A State N/A Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip/Postal Code: Country: Foreign Application (Outside U.S.) $40US ($3.35/mo*) Phone Number: Email Address:

Annual Dues: $35 Renewal for all members who already have an ATCA membership number ($3/mo*) ATCA Membership number: I would like to run for office $35 Annual membership for New Members who never had an ATCA membership number ($3/mo*) Currently $35 until the end of the year. Fill this into the Total below. $10 Spousal associate member, Paperless Spouse Name: Spouse Membership Number: $10 Student (under 18 yrs) member, Paperless New Member Renewing Member Date Of Birth: Month January February March April May June July August September October November December Year 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 Membership Number:

Paperless Membership - Save $5 US ($10 Foreign) when you sign up for a full year paperless membership!($2.50/mo*) With a paperless membership you will still receive all of the benefits of a regular membership but monthly newsletters will only be available on our website atcaonline.com in the members section. I, the undersigned, hereby make application for membership in the ANTIQUE TELEPHONE COLLECTORS ASSOCIATION and agree to uphold the rules, regulations and By-Laws of the Association. Dues are paid on a calendar basis January through December. Articles of Incorporation Total: $(USD) - Includes a $1.50 Surchage to cover PayPal Fees *All dues are pro-rated at the monthly amount if you join anytime after June.