Elongated Coin Database Submission Form

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Mark all the following that apply:

This is a modification to an existing record. ID #
I maintain a specific ID # for this coin. My ID # is

This is a brand new machine.
This machine has been retired.

Your Name:
Date you last visited this machine:

State:

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Alaska	Florida	Kansas	Minnesota	New Hampshire	Ohio	South Dakota	Washington
Arizona	Georgia	Kentucky	Mississippi	New Jersey	Oklahoma	Tennessee	Washington DC
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City: Location:

Coin: Penny Nickel Dime Quarter Slug Foreign

Machine Type: Electric Hand Crank

Die #1	Die #2	Die #3	Die #4
Orientation:	Orientation:	Orientation:	Orientation:
Horizontal Vertical	Horizontal Vertical	Horizontal Vertical	Horizontal Vertical
Border:	Border:	Border:	Border:
Ex: Rope, Dot, None...	Ex: Rope, Dot, None...	Ex: Rope, Dot, None...	Ex: Rope, Dot, None...
Image:	Image:	Image:	Image:
Please be detailed	Please be detailed	Please be detailed	Please be detailed
Text:	Text:	Text:	Text:
Use "-" for breaks in flow of text	Use "-" for breaks in flow of text	Use "-" for breaks in flow of text	Use "-" for breaks in flow of text

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