Event Information:

• Membership Application Form

  Title First Name, Last Name (Required)
  [select* name_title id:application-title "Mr" "Mrs" "Ms" "Dr" "Prof"] [text* first_name id:application-first-name 25/50 placeholder "First Name"] [text* last_name id:application-last-name 25/50 placeholder "Last Name"]

  Postal Address (Required)
  [textarea* postal_address 46x3 placeholder "Postal Address"]

  City (Required)
  [text* contact_city 50/50 placeholder "City"]

  State (Required)
  [text* contact_state 25/50 placeholder "State"]

  PostCode / ZIP (Required)
  [text* contact_postcode 10/10 placeholder "Postcode/ZIP"]

  Country (if not Australia)
  [text contact_country 25/50 placeholder "Country (if not Australia)"]

  Email (Required)
  [email* email_address 50/100 placeholder "Email Address"]

  Contact Phone Number
  [tel contact_telephone 50/50 placeholder "Telephone"]

  Preferred Method of Contact
  [radio radio-contact-method label_first default:1 "Post" "Email" "Phone"]

  Share my contact details with other members of the Association
  [select* menu-share-contact-details "DO NOT SHARE my details" "Share my Details"]

  My Collecting Interests Are:
  [textarea* numismatic_interests 46x3 placeholder "Numismatic Interests"]

  Payment Details

  I wish to pay my subscription by
  [select* menu-payment-details include_blank "Cheque" "Direct Deposit" "PayPal"] [recaptcha id:Member] [submit "Submit Application"]

  1
  NAV Online Membership Application
  membershipform@nullnavic.org.au
  info@nullnavic.org.au
  From: [first_name] [last_name] <[email_address]>
  Subject: NAVIC Online Membership Application

  Application Date: [_date] Name: [name_title] [first_name] [last_name] Address: [postal_address] City / State / Postcode: [contact_city] [contact_state] [contact_postcode] Country: [contact_country] Email: [email_address] Telephone: [contact_telephone] Preferred Contact Method: [checkbox-contact-method] Share Contact Details: [menu-share-contact-details] Collecting Interests: [collecting_interests] Payment Method: [menu-payment-details] -----------------------------------------------
  This e-mail was sent via the Membership Application form on The Numismatic Association of Victoria Website (https://www.navic.org.au)
  Reply-To: [email_address]

  Your application has been submitted, thank you. Please forward membership payment as detailed below.
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  The field is required.
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  The date format is incorrect.
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  There was an unknown error uploading the file.
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  There was an error uploading the file.
  The number format is invalid.
  The number is smaller than the minimum allowed.
  The number is larger than the maximum allowed.
  The answer to the quiz is incorrect.
  Your entered code is incorrect.
  The e-mail address entered is invalid.
  The URL is invalid.
  The telephone number is invalid.