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Application Form
Please print this form, fill it out, and mail it to:

FRIENDS OF THE SEGOVIA MINT
Apartado 315
E-40080, Segovia, SPAIN

Name___________________________________________________

Address_________________________________________________

City_______________________________  Postal code___________

State / Province________________    Country____________________

Telephone___________________________    Fax________________

E-mail_____________________@___________________________

I authorize the listing of my e-mail address on the Association's web site.

ANNUAL DUES:  2.000 pesetas (12 euros) ($15 US)

PAYMENT METHODS:

Money order or postal draft made out to the Association

Personal check made out to the Association

Direct deposit in the Association's account in the Caja de Ahorros de Segovia:
Account code: bank 2069 office 0001 control 9 3 account 000157761 1

Authorization for automatic withdrawal.

I authorize my bank to automatically pay my annual dues to the FRIENDS OF THE SEGOVIA MINT Association from my following account (please fill in the information):

My bank's name and address___________________________________________

Bank___________ Office________ Control______ Account___________________


(Date)____________________  (Signature)_______________________________