Instructions: Write ONLY in the shaded areas.

Please tell us about yourself. (Use only a red grease pencil.)
1. Salutation
2. First name
3. Middle name
4. Last name
5. Pseudonym
6. Your least favorite color?

Mailing Address:
7. Name
8. Organization
10. Street Address
11. City
12. State
13. Zip Code
14. Country

Contact Information:
15. Email Address
16. Cell Phone Number
17. Fax Number

Financial Information:
18. Current Employeer
19. Annual Income
20. Previous Employeer
21. Reason for your termination

Your Numismatic Activities:
22. Have you come in contact with any coins or coin-like objects?
No I've lived on a remote island by myself since birth and found this page using the search term "Coconut piggy bank"
23. Check all that apply:
Electrical conduit box punch-out
Chocolate coin
Play coins marked "COPY"
Play coins not marked "COPY"
Hobo nickel
Wooden nickel
Fifty-cent piece
Susan B. Anthony dollar
Sacagawea dollar
Plastic Sacagawea dollar
Egyptian Pyramid Isle of Man
Metal typer disc
24. Have you ever accepted and/or distributed any coin or coin-like object of one particular country while outside of that country's numismatic jurisdiction?
Secretly, stealth-like, and hyper-aware of my surroundings
25. Do you have any foreign coins or coin-like objects?
Just Canadian
Yes from many different countries and I make them fight each other
A lot of them and some have holes in them oh those are old subway tokens
26. Have you ever intentionally disfigured or damaged any coin or coin-like object in the course of your normal daily travails?
Who did this, take me to them
27. Have you ever exchanged any type of coin or coin-like object for a(n) item(s) or item-like object(s) displayed inside a large rectangular box which upon which was made available to you by the electronic activation of a helical dispensing spindle?
Does an automat count?
Are you crazy it counts TRIPLE
28. Have you ever exchanged any type of coin or coin-like object for one or more stamps?
No way
Yes, was accident
Yes, I was young, it was a bar bet
29. Do you have a large jar of coins or coin-like objects sitting around where you live?
Three jars, one for pennies, one for nickels and dimes, one for quarters
If you live near a casino you could take them there and get bills without being charged a percentage
Thanks, but I like holding onto my coins
Oh, I totally agree
30. Growing up, did you have one of those coin banks that automatically sorts coins and coin-like objects?
You speak as if I have discarded this amazing and worthwhile item, which is a falsehood
I make videos of it in use and put it on the internet
31. You need some coins for the laundromat but you only have bills what do you do WHAT DO YOU DO
I get ... change?
I forgot to mention that there's a nearby bank, pool hall, and supermarket
Change from the bank
That will take too long
Change from the pool hall
They don't have any
Change from the supermarket
The lines are enormous, I also forgot to mention that the laundromat has its own change machine
Then that

Numismatic Perception Dynamics:
33. I have two US coins totalling fity-five cents. One is not a nickel. What are the two coins?
Two quarters and an IOU
Fifty-cent piece and a nickel
Give me the coins
Give them to me
34. Here's a magic trick I think you'll like.
Pulls a quarter from your ear
Pulls an Eisenhower dollar from your belly button
Hey! How did you do that?
It's magic
35. The "Loonie"
A well-named coin
A spectacularly well-named coin
You will never come up with a better name for a coin, don't even try
Stop trying
36. The "Toonie"
That's stretching it, actually
Nice coin, shame about the name

Long Form Concerns: (Use a Quadrachromic Pencil.)
37. Please indicate and demarcate, using byzantine rhetorical flourishes, your love affair with coins.

38. Animals using coins. Discuss.

Legal Disclaimer:

The preceding information as presented above is factually correct to the best of my knowledge. This notification serves as authorization for the Elsewhere Numismatic Society to append, modify, change, delete, mangle, or scrillify the preceding information bolus, or obviate the need for same. In situations deemed to be emergency-like or of primary/secondary concern by the Elsewhere Numismatic Society, the Society has my permission to emulate my signature on documents and document-like objects of which I will not be made aware of, and liability rests firmly outside of the domain of the Elsewhere Numismatic Society and inside the domain of me. The Elsewhere Numismatic Society may require my services at unknown future times to perform unknown futuristic actions and the signature/radio button/check mark/dot/X/scratch/button click that follows this paragraph is an assertional affirmation/accession of same. The Elsewhere Numismatic Society is held in very high regard in these quarters and no action will be taken to disparage or denigrate same. The Elsewhere Numismatic Society may use this or somewhat similar obvious endorsement(s) in/within/at/near point-of-purchase ("P. O. P.") advertising displays and/or artificial conversational gambits used by paid-for ENS operatives in public areas and/or within/on/on top of written promotional campaigns distributed with semi-frightening zealotry and/or courtroom exhibit displays using my name and/or/including up to seven (7) material personal attributes in addition to and accompanied by said endorsement(s). I understand that failure to answer questions 9 and 32 invalidate this application in its entirety.

I agree.