American Council of the Blind Membership Application

Date:

Name:

Home Phone:

Mobile Phone:

Work Phone:

Street Address:

City:

State:

ZIP Code:

E-mail Address:

Birthday:

Are you blind or visually impaired according to the legal definition of blindness?

Yes:                       No:

i\If you are not currently receiving the Braille forum or if you would like to change the medium in which you receive it, please check one of the following.

Large Print:

Braille:

Four-track Cassette (through 2012):

IBM-compatible CD:

E-mail (Must include e-mail address):

Would you like us to submit for the e-mail edition?:    yes:             no:

or

to get the Braille forum by e-mail: see the Braille Forum page at acb.org for further instructions.

Application Submitted By:

Referring Memberís Name:

Phone:

***Please make checks payable to Albuquerque Chapter, ACB NM***

Yearly Dues: $10.00

ACB = American Council of the Blind

NM = New Mexico

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