THE ORIGINAL HOBO NICKEL Society, inc.

HOBO NICKEL QUALITY DESIGNATION FORM

- Print and mail to one of the examiners below -

Submission will be reviewed by two OHNS examiners who will give independent opinions as to the quality of the carving (with explanation and/or observations), subject, and probably artist. A photograph of the coin will be taken to accompany the report. Originals of the report and photograph will be returned along with the coin to the owner and copies will be kept by (1) the examiner and (2) in the OHNS archives. Please fill out one form for each coin submitted and mail coin(s), form(s) and payment to one of the following examiners:

Bill Fivaz P.O.Box 888660 Dunwoody, GA 30356-0660

Steve Alpert P.O.Box 66331 Los Angeles, CA 90066-0331

Owner's Name:_______________________________________ OHNS Membership No.:___________

Address:____________________________________________ EMail:_________________________

City:_______________________________________________ State:_______ ZIP:_______________

Owner's value of coin (necessary for insurance):$________________
Fees: $15 per coin; 10 or more coins @ $12.50 ea.; $25 per coin for non-members
Fee includes first class postage and $100 insurance per coin.

For ADDITIONAL INSURANCE and/or REGISTERED MAIL: Please enclose an additional $5.00 per coin, per each additional $500 of insurance (or fraction therof, up to a maximum of $25 for all coins submitted). If registered Mail is desired on a single coin submission, add an additional $10.

I understand the opinions rendered are strictly that, and are not a guarantee of value or authenticity. It is, however, the best considered judgment by qualified specialists in the field; but, others may reach different conclusions.

[  ] ... I authorize OHNS to use a photograph of this coin.       [  ] ... I authorize OHNS to use my name (not address).

Signature of owner_____________________________________________  Date________________

Please make all checks payable to: ORIGINAL HOBO NICKEL SOCIETY