ANA Member Submitter Application - NGC

ANA Member Submitter Application

If you have an active membership with NGC and PMG you should not complete this application. A membership with the American Numismatic Association (ANA) is required when filling out this form. For ANA membership information, please call 800-367-9723 or visit

Please read and complete the entire form. All information is held in the strictest confidence.

Collecting Interest Select your collecting interest (choose one): Coins Paper Money

Correspondence Information Title Mr. Ms. Mrs. Dr. Name: Address: City: Country: Phone:

ANA Membership #: Apartment, Suite, Floor: State/Province: Email Address: Fax:

Exp. Date: ZIP/Postal Code:

Website Access Your email will serve as your username for the NGC and PMG websites. An email will be sent to the address you listed above to create a password. Public/Display Name:

This is the name that will be visible to the public on the Chat Boards and in NGC and PMG Registries, if you choose to participate in either.

Execution Of Agreement (Required-Application will not be processed without signature.) By completing and signing this application and agreement, I (i) represent that I have, and during the term of this agreement will have, a valid ANA membership; and (ii) authorize CCG to disclose my identifying information (including, without limitation, my name, address, ANA membership number, and ANA membership expiration date) to the ANA for the purpose of confirming the status of my membership. I understand that my Collectors Society membership with CCG shall be subject to immediate termination if, at any time, I do not have a valid membership with the ANA. I agree to be bound by the Terms and Conditions of Collector Membership (legal/member-agreement), which are hereby incorporated by reference.

AUTHORIZED SIGNATURE REQUIRED_________________________________ Print your name_________________________________________ Date__________________

Mail to: CCG P.O. Box 4711 l Sarasota, FL 34230 or FAX TO: 941-360-2553

0222-500 7236

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