PLEASE ENTER YOUR REFERENCE NUMBER BELOW, OR OPEN IN ADOBE ACROBAT TO

GENERATE NUMBER
T H I S S U B M I S S I O N F O R M I S F O R P C G S B A N K N O T E G R A D I N G I N P A R I S O N L Y.
PARIS SUBMISSION FORM PARIS SUBMISSION #
Collectors Universe Inc. – PCGS
92 rue de Richelieu, Escalier G, 2nd floor VAT #:______________________________________
75002 Paris, France • Tél : +33 (0) 1 40 20 09 94 Authorized Dealer/Collectors Club Member Name:����������������������������������
www.PCGSeurope.com/banknotes
Banknotes@PCGSeurope.com PCGS Authorized Dealer/Collectors Club #:����������������������������������������
M Join the PCGS Collectors Club for 69€ per year (You must be a PCGS Authorized Dealer or Collectors Club member to submit banknotes.)
PASSPORT INFORMATION (print clearly) PACKAGE INFORMATION: (Customer Must Provide)
Total submission forms (orders) in this package: ________________________________
NAME (as written on your passport)�������������������������������������������������
PASSPORT NUMBER & COUNTRY���������������������������������������������
SUBMISSION RETURN (choose one) PCGS BANKNOTE GRADING USE ONLY
M Pick up at the PCGS Submission Center
LEGAL ADDRESS (for return shipping)
M Show Pick Up (when available) ORDER #____________ BOX________
NAME������������������������������������������������������������������ ________________________________
A valid passport that matches the

ADDRESS��������������������������������������������������������������� name/number on the submission form ITEM #_________________________
���������������������������������������������������������������������� must be presented in order to pick up
your banknotes.
CITY_____________________________ COUNTRY������������������������������ M Ship directly to client. INV. TYPE CODE__________________
EMAIL������������������������������������������������������������������ (Client must make prior arrangements

with PCGS Banknote Grading.)
PHONE ( _____ )������������������������������������������������������������ 
Tel.: +33 (0) 1 40 20 09 94 DATE RECEIVED__________________

A. T YPE OF SUBMISSION: (Choose one per form) M Grading M Regrade M Reholder (See reverse for definitions) GRADING OPTIONS: M Standard M Genuine Only
B. SERVICE LEVEL: (Choose one per form)
Max. Note Grading Fee Max. Note Grading Fee Max. Note Grading Fee
Service Level Value (€) Excludes VAT (€) Service Level Value (€) Excludes VAT (€) Service Level Value (€) Excludes VAT (€)
M Rarity No Limit 300 M Regular 3,000 45 M Bulk*
300 POR
(Min. of 50 Notes, Same Type)
M High Value 100,000 185 M Economy 1,000 25
M Reholder No Limit 10
M Premium 20,000 85 M Modern (1961 to Date) 300 16
For banknotes that require the use of an oversized holder (19.5cm x 21cm) there is an additional fee of 10€ per banknote. *Contact PCGS Banknote Grading in Paris for bulk pricing.

C. COMPLETE DETAILED BANKNOTE INFORMATION

Oversized Declared Value
Type
Qty. Country Catalog # Date/Series Denom. Serial Number/ Pedigree (Pre-Approval Required) Holder 10€
(if applicable) (Required)
(if applicable)

0 1 France 147C 1970 10 Francs 232819 — The Hall Collection □ 400€

1 □

2 □
.
3 R D ER□S
O D.
U R ATE ADE□
4
CC G R
R INA ED UN
O
URN
5 □
L E TE E T
MP R
CO BEING
6 □
I N
R TE
7
I B L E FO IN NO □

N S L T
8
PO SU □

E RES AY RE
9 TB M
NO FORM
□

L L
WI ON
NG MISSI
10 □
D I
11 GRA TE SUB □
O TE L E
K N M P
BAN O CO
12 □
G S T
13 PC URE □
FAIL
14 □

15 

SUBTOTALS:

H. METHOD OF PAYMENT:
D. FEE CALCULATION: ____________ x _____________________��������������������������������������������������= €_____________ 
All fees must be authorized before PCGS Banknote Grading can process your order.
# of Banknotes Service Level Fee Failure to authorize all appropriate fees for your submission will delay your order.
PCGS Banknote Grading reserves the right to correct the submission form to reflect
current and appropriate Grading fees .
E. ADDITIONAL FEE (where applicable): Cash Wire Transfer Check
Oversized Holder (banknotes larger than 19.5cm x 21cm) (total from above) ��������������������������= €_____________ Credit Card (Visa or MasterCard)
Credit Card No.�����������������������������������������
F. COLLECTORS CLUB MEMBERSHIP ������������������������������������������������������������������������������������������= €_____________
Exp. Date___________________ CCV Code������������������

G. TOTAL CHARGES: (add lines D – F)��������������������������������������������������������������������������������������������= €_____________ Cardholder Signature�������������������������������������

I HAVE READ AND AGREE TO THE PCGS BANKNOTE GRADING TERMS AND CONDITIONS ON THE BACK OF THIS FORM AND I ACCEPT FULL RESPONSIBILITY FOR
COMPLETELY AND ACCURATELY FILLING OUT THE SUBMISSION FORM. IF BANKNOTES ARE SUBMITTED FOR SERVICES FOR WHICH THEY DO NOT QUALIFY, TOTAL DECLARED VALUE € ________________
I AUTHORIZE PCGS BANKNOTE GRADING TO CORRECT THE ORDER AND CHARGE ANY ADDITIONAL GRADING FEES THAT MAY APPLY. (from above) Required
AUTHORIZED SIGNATURE (REQUIRED)   will not be processed without signature DATE
Order
PLEASE SEE REVERSE FOR SUBMISSION INSTRUCTIONS AND TERMS AND CONDITIONS

Please read carefully. Following these directions will
help expedite your order.
1. Please print your VAT #, name, dealer/club number,
passport information, legal address, email address, and
phone number in the spaces provided. Grading fees do
not include VAT. You must be a PCGS Authorized
Dealer or Collectors Club member to submit banknotes.
If you are not a Collectors Club member you may elect to
join on this form for 69€ per year.
2. Package Information (required) – Please provide the
total number of orders in the package. If this is the only
order you are submitting, the number should be one.
3. Section A – Select the Type of Submission. ONLY
ONE TYPE OF SUBMISSION AT ONE SERVICE
LEVEL IS PERMITTED PER SUBMISSION FORM.
DEFINITIONS
GRADING: For banknotes not encapsulated or graded
by any grading service.
REGRADE: For banknotes previously certified by PCGS
Banknote Grading that you feel might be worthy of a
higher grade. Submit the banknotes in the PCGS
Banknote Grading holder. Banknotes submitted under
the regrade service will be removed from the holder and
regraded. If the banknote grades lower, the terms of the
PCGS Banknote Grading guarantee will apply. For full
disclosure on the PCGS Banknote Grading guarantee,
visit www.PCGSeurope.com/banknotes/guarantee.
REHOLDER: For the re-encapsulation of PCGS
Banknote Grading certified banknotes. Any banknote
submitted under the reholder service will not be regraded.
GRADING OPTIONS: Please select “Standard” to have
your banknotes graded numerically or select “Genuine
only” for authentication only.
Currently PCGS Banknote Grading does not offer the
Crossover service. Banknotes certified by other third-party
grading companies, that are submitted to PCGS Banknote
Grading, will be removed from their existing holder and
graded as raw.
By signing the front side of this form, Customer acknowl-
edges that they have read the Collectors Universe (Paris)
Limited-PCGS Banknote Grading (“PCGS Banknote
Grading”) Terms and Conditions (the “Agreement”) set forth
below and agrees to abide by this Agreement, and further
agrees that PCGS Banknote Grading is entitled to rely upon
and benefit from this Agreement.
1. PCGS Banknote Grading will endeavor to grade banknotes
within the time frame, if any, offered as part of a PCGS
Banknote Grading service. However, PCGS Banknote
Grading will have no liability whatsoever to Customer for
incidental or consequential damages due to PCGS Banknote
Grading’s failure to grade any banknote within any time
frame. All days are business days.
2. PCGS Banknote Grading will not grade banknotes that
appear to be significantly altered or are of questionable
authenticity. If PCGS Banknote Grading rejects any
banknote for grading in accordance with PCGS Banknote
Grading’s grading standards and procedures, PCGS Banknote
Grading shall not refund the fee paid by Customer. Customer
represents and warrants that they has no knowledge and no
reasonable basis to believe that any banknote submitted for
grading has been altered or Doctored in any way. For pur-
poses of this Agreement, “Doctored” shall have the meaning
set forth in the applicable PCGS Authorized Dealer
Agreement or PCGS Collectors Club Agreement by and
between Customer and PCGS (the “Customer Agreement”).
If Customer has not entered into the Customer Agreement,
Customer hereby agrees to be bound by the terms of the
Customer Agreement, a copy of which can be found at
www.PCGS.com, and Customer’s signature on this
Agreement shall constitute Customer’s acceptance to be
bound by the terms and conditions of Customer Agreement
including its obligations with respect to Doctored banknotes
set forth in the Customer Agreement. Customer warrants that
all information provided herein is accurate and reliable and
undertakes to promptly correct and update such information
if Customer discovers any such information is inaccurate.
3. Grading involves individual judgments that are subjective
and require the exercise of professional opinion, which can
change from time to time. Therefore, PCGS Banknote
Grading makes no warranty or representation and shall have
no liability whatsoever to Customer for the grade assigned by
PCGS Banknote Grading to any banknote, except pursuant
to PCGS Banknote Grading’s Guarantee Resubmission
as set forth on PCGS Banknote Grading’s website at
www.PCGSeurope.com/banknotes/guarantee, which by sign-
ing this agreement the Customer acknowledges they have read
and accepts the terms and conditions of the PCGS Banknote
Grading Guarantee.
4. PCGS Banknote Grading will exercise reasonable care in
Packaging banknotes submitted for grading, regrading or
reholdering. However, if PCGS Banknote Grading deter-
©2016 Collectors Universe, Inc. 
SUBMISSION INSTRUCTIONS
4. Section B – Select the Service Level by referring to the 8. Section F – Collectors Club Membership. If you have
PCGS Banknote Grading Services and Fees. Please note selected the option to join the PCGS Collectors Club,
the minimum requirements and restrictions within each add the 69€ membership fee.
service level. 9. Section G – Total Charges. Add the charges from
5. Section C – List the details for each banknote in the Sections D-F and provide the total cost for the
following area. ­submission.
• Quantity – List the total number of banknotes (per 10. Section H – Method of Payment. Select the method
line). If you have multiple of the same banknote, you can of payment and provide payment details. The following
list them on the same line. options are accepted: Cash, Bank Wire Transfer, Check
• Country – List the Country where the banknote was or Credit Card (Visa or MasterCard). You must include
issued. payment or your order will not be processed. Sign on the
space provided.
• Catalog # - Provide the catalog number for each
banknote. 11. Read Terms and Conditions. Sign and date at the
bottom of the form to accept the PCGS Banknote
• Date/Series – List the date or series of the banknote.
Grading Terms & Conditions (located below). Order will
• Denomination – List the denomination of the banknote.
not be processed without signature. Keep blue copy for
• Type – List the type of banknote here (if applicable).
your records.
• Serial Number and Pedigree – Notate the serial number
and any pedigree requests. For multiple notes with 12. Place each banknote in a new mylar sleeve (only one
­consecutive serial numbers, list the range of numbers. All banknote per sleeve). Do not send banknotes with staples.
Pedigree requests must be pre-approved. Package banknotes and submission form carefully.
• Oversized Holder – For banknotes that require the use 13. Submissions can either be delivered in person to the
PCGS Banknote Grading Paris Submission Center (by
of an oversized holder (larger than 19.5cm x 21cm), there
appointment only) or shipped directly to us. Mail all
is an additional fee of 10€ per banknote. Select the option
banknote submissions to PCGS Banknote Grading Paris
in this area.
Submission Center 92 rue de Richelieu, Escalier G, 2nd
• Declared Value – Each banknote requires a declared
floor 75002 Paris, France. Packages to PCGS Banknote
value (per banknote). List the assigned value for each
Grading must be insured by the Sender. Completed sub-
banknote in this area. NOTE: This value must coincide
missions will be held at PCGS until picked up, unless
with the selected service level (from Section B).
return shipping has been previously arranged with PCGS
• Subtotals – Calculate the subtotals for each column and Banknote Grading. Note: All terms and conditions are
list in this area (Oversized Holder Fee and Declared subject to change. Estimated turnaround times do not
Value). include mailing time and reflect business days.
6. Section D – Fee Calculation. List the number of IF MORE THAN ONE TYPE OF SUBMISSION OR
banknotes multiplied by the service level fee and total on SERVICE LEVEL IS INCLUDED ON ANY ONE
this line. FORM, YOU AUTHORIZE PCGS BANKNOTE
7. Section E – Additional Fee. If banknotes require the GRADING TO SEPARATE THE ORDER FOR
use of an oversized holder (see Section C), calculate the PROCESSING AND AGREE TO PAY ANY
totals and list the fee in this area (where applicable). ADDITIONAL GRADING FEES THAT MAY APPLY.
PCGS GRADING TERMS & CONDITIONS
mines that the Customer’s banknote was lost or damaged Turnaround times do not include mailing time and reflect Banknote Grading in its sole discretion deems appropriate,
while in PCGS Banknote Grading possession, Customer will business days. including, but not limited to, the publication and republica-
be compensated based upon the fair market value of the 9. Except as expressly set forth herein to the contrary, PCGS tion or reproduction in or on any media, of such Data and
banknote as determined by PCGS Banknote Grading stan- Banknote Grading DISCLAIMS ANY AND ALL Images. Without limiting the generality of the foregoing,
dard procedures which may include filing a claim with our WARRANTIES, EXPRESSED OR IMPLIED, Customer, on behalf of itself and any third party for whom
insurance carrier. The declared value you stated on the front REGARDING PCGS BANKNOTE GRADING’S GOODS Customer may be acting with respect to this agreement,
of this form is for estimating the insurance coverage only, and AND SERVICES, INCLUDING BUT NOT LIMITED unconditionally and irrevocably transfers, conveys and assigns
the fair market value of the banknote may be less than your TO THE WARRANTIES OF MERCHANTABILITY to PCGS Banknote Grading any and all current and any here-
declared value. IN NO EVENT SHALL THE TOTAL AND FITNESS FOR A PARTICULAR PURPOSE. after acquired rights, title and interests (including, without
LIABILITY EXCEED THE DECLARED VALUE OF THE 10. Notwithstanding anything to the contrary contained limitation, rights in copyright, patent, trade secret and trade-
BANKNOTE. herein, except with respect to the remedies under the PCGS mark) that Customer or any such third party may have in or
5. Customer must inspect all banknotes immediately upon Banknote Grading Guarantee of Grade and Authenticity set to the Data and the Images (on whatever media or in what-
receipt and PCGS Banknote Grading disclaims any liability forth at www.PCGSeurope.com/banknotes/guarantee (the ever form such Images may be reproduced or published).
for damage or discrepancies or errors, including but not lim- “Guarantee”) and as set out in paragraph 4 above in connec- 12. If any banknotes are being submitted for a third party,
ited to errors in the description of the banknote, unless tion with the loss or damage to a banknote while in the pos- Customer represents and warrants that such third party has
reported to PCGS Banknote Grading within five (5) days of session of PCGS Banknote Grading THE MAXIMUM agreed and accepted this Agreement and has signed a dupli-
Customer’s receipt of the banknote(s). Customer agrees to AGGREGATE LIABILITY THAT PCGS BANKNOTE cate copy hereof where indicated. Customer agrees to provide
return any incorrectly described banknote to PCGS Banknote GRADING SHALL HAVE TO CUSTOMER, OR ANY that third party-signed copy to PCGS Banknote Grading at
Grading upon request for correction and agrees to indemnify THIRD PARTY FOR WHOM THE CUSTOMER MAY any time upon its request.
and hold PCGS Banknote Grading harmless from any and all BE ACTING, ARISING FROM ANY CAUSE, ACT, 13. This Agreement is governed and construed in accordance
losses and/or claims caused by the circulation or sale of any OMISSION OR OTHER CIRCUMSTANCE, SHALL IN with the laws of France. Exclusive jurisdiction shall be granted
incorrectly described banknote. NO EVENT EXCEED THE GRADING FEE OR to the Commercial Court of Paris for any dispute relating to
6. Customer agrees (a) to pay to PCGS Banknote Grading all AMOUNT ACTUALLY PAID BY CUSTOMER FOR these terms and conditions. Customer accepts and agrees not
fees and other charges when due; (b) that all fees are exclusive THE GRADING SERVICES RENDERED BY PCGS to challenge the jurisdiction or venue of such court or assert
of local taxes; (c) that any delinquent balances shall accrue BANKNOTE GRADING WITH RESPECT TO THE that it is not a convenient forum.
interest at the rate of 10% per year until paid (or, if less, the BANKNOTES SUBMITTED FOR GRADING 14. The terms and provisions in this Agreement and the
maximum interest rate permitted by applicable law); and (d) HEREUNDER. IN NO EVENT SHALL PCGS Customer Agreement, if applicable, constitute the entire
that PCGS Banknote Grading shall have a security interest in BANKNOTE GRADING OR ANY OF ITS AFFILIATES, agreement of PCGS Banknote Grading and Customer (and
the banknotes submitted, as well as in any other property of OR ANY OF ITS OR THEIR RESPECTIVE EMPLOYEES, any third party for whom Customer may be acting) regard-
Customer in the possession of PCGS Banknote Grading or its OFFICERS, DIRECTORS OR AGENTS, BE LIABLE TO ing, and supersede all prior agreements and understandings
affiliates (collectively, the “Property”), to secure payment CUSTOMER OR ANY OTHER PARTY FOR ANY (written or oral) between or among such parties relating to,
thereof. Customer hereby grants to PCGS Banknote Grading INDIRECT, INCIDENTAL, SPECIAL, the subject matter hereof. Except for the dispute resolution
an assignment of and lien against the Property in the amount CONSEQUENTIAL OR EXEMPLARY DAMAGES, provision set forth in Section 24 of the PCGS Authorized
of any fees and other charges due and payable pursuant to the EVEN IF ADVISED OF THE POSSIBILITY OF SUCH Dealer Agreement (which shall control over Section 13 of
terms of this Agreement. Customer hereby authorizes PCGS DAMAGES. this Agreement), if it is determined that there are any incon-
Banknote Grading to file, at any time on or after the date such 11. In the ordinary course of its grading operations, PCGS sistencies between this Agreement and the Customer
fees and other charges become due, appropriate uniform com- Banknote Grading (i) compiles data regarding each banknote Agreement, then this Agreement shall control. If any term or
mercial code financing statements in such jurisdictions and submitted for grading, including, but not limited to, data provision of this Agreement is determined, by a final and
offices as PCGS Banknote Grading deems necessary in con- relating to the identity, minting, condition and grade of the non-appealable ruling or order of a court of competent juris-
nection with the perfection of a security interest in the banknote (the “Data”); and (ii) may take, or have taken, one diction, to be invalid or unenforceable under applicable law,
Property. or more digital or other types of photographs, images or such invalidity or unenforceability shall not affect the valid-
7. PCGS Banknote Grading shall have no liability whatsoever reproductions of each such banknote (collectively, the ity or enforceability of any of the other of the terms or provi-
to Customer, or any third party for whom Customer may be “Images”). In consideration for the grading services being sions of this agreement. Each party shall execute and deliver
acting, for (i) any personal injury or (ii) for any damage to any provided by PCGS Banknote Grading, Customer, on behalf such additional documents and instruments as any other
banknote, or otherwise, that Customer is unable to demon- of itself and any third party for whom Customer may be act- party may request to better evidence or effectuate the agree-
strate was attributable primarily to an act or omission to act ing, hereby authorizes PCGS Banknote Grading (i) to com- ments contained herein, including the assignment of rights
by PCGS Banknote Grading while the banknote was in its pile and maintain such Data with respect to each banknote set forth in Section 11, and procedures, and further agree
possession and control, except for any damage to a banknote submitted hereunder for grading; and (ii) to take, or cause to that PCGS Banknote Grading is entitled to rely upon and
resulting from the breaking open by PCGS Banknote be taken, one or more Images of each such banknote, and benefit from those terms and procedures.
Grading of a PCGS Banknote Grading or other banknote further agrees that PCGS Banknote Grading will be the 15. If it is determined that there are any inconsistencies
holder in which the banknote may have been submitted for owner of such Data and all such Images and that PCGS between this agreement and the English language version of this
grading to PCGS Banknote Grading. Banknote Grading may use and exploit such Data and the agreement, then the English language version shall control.
8. Note all terms and conditions are subject to change. Images for commercial and any other purposes, as PCGS CUSTOMER: SIGN FRONT OF FORM
602106h [paris.os.en.a4] 02/16