Arizona Council of the Blind, INC. f3124 E. Roosevelt St., Ste. 4 Phoenix, AZ 85008-5088 (602) 273-1510
MEMBERSHIP APPLICATION
Membership in the Arizona Council of the Blind is an adventure we want you to share. We hope you will get involved.
The Arizona Council of the Blind gives you a voice in our state and nation. Come, take our hand, and join our adventure.
Fill in the form below and submit.
Dues is the sum of State (AzCB) Membership plus the dues charged if you wish to also be a member of one or more Affiliates. Arizona Council of the Blind (AzCB) dues are $10.00. Affiliate dues are $3.00 Maricopa Club, $5.00 Southern Arizona Chapter, $5.00 Phoenix Group, $10.00 Guide Dog Users of Arizona. Is this a renewal or a new member application? (Check one): Renewal Application. Renewal New Member Application. New Member
TODAY'S DATE (MM/DD/YYYY): Todays Date MM/DD/YYY
BIRTHDAY (MM/DD/YYYY): Birthday MM/DD/YYY
$10.00 Dues for the Arizona Council (AzCB plus any Affiliates.
Total all the boxes checked and put amount here ($10.00 just the State Membership to $33.00 for all the Affiliates) Total of AzCB and Affiliate Memberships.
Name: Full Name Address Line 1: Address line 1 Adress Line 2: Address Line 2 City: City State/Province: State ZIP Code/Postal Code: Zip Code Telephone: Phone NUMBER: Full Phone Number including area code. Email Address: Your Email Address OCCUPATION: Occupation Vision - CHECK ONE: Vision is Sighted Vision is partially Sighted Vision is Blind NEWSLETTER PREFERENCE for Fore-Sight (newsletter of the Arizona Council) Check one: Arizona Newsletter on Audio Tape Arizona Newsletter in Large Print Arizona Newsletter by Email Arizona Newsletter in Braille Do Not Send Arizona Newsletter ACB BRAILLE FORUM (newsletter for NATIONAL) check one: National Newsletter in Large Print National Newsletter on Cassette Tape National Newsletter in Braille National Newsletter by Email Do Not Send National Newsletter How did you hear about AzCB? Learned about AzCB from Friend. Learned about AzCB from Radio/TV Show. Learned about AzCB from Web Search. Learned about AzCB from Web Ring. Learned about AzCB from Newsletter. Learned about AzCB from Other Source. If other please tell us how? Method of payment (i.e. PayPal or Print and Mail) Will mail in payment. Will use PayPal. Using PayPal on next screen Mailing dues Comments: Type comments here. Submit will send an E-mail of this form to the AZCB. Return to AzCB Web Site
Email Address: Your Email Address
OCCUPATION: Occupation
Vision - CHECK ONE: Vision is Sighted Vision is partially Sighted Vision is Blind
NEWSLETTER PREFERENCE for Fore-Sight (newsletter of the Arizona Council) Check one: Arizona Newsletter on Audio Tape Arizona Newsletter in Large Print Arizona Newsletter by Email Arizona Newsletter in Braille Do Not Send Arizona Newsletter
ACB BRAILLE FORUM (newsletter for NATIONAL) check one: National Newsletter in Large Print National Newsletter on Cassette Tape National Newsletter in Braille National Newsletter by Email Do Not Send National Newsletter
How did you hear about AzCB? Learned about AzCB from Friend. Learned about AzCB from Radio/TV Show. Learned about AzCB from Web Search. Learned about AzCB from Web Ring. Learned about AzCB from Newsletter. Learned about AzCB from Other Source.
If other please tell us how? Method of payment (i.e. PayPal or Print and Mail) Will mail in payment. Will use PayPal. Using PayPal on next screen Mailing dues Comments: Type comments here. Submit will send an E-mail of this form to the AZCB. Return to AzCB Web Site
Method of payment (i.e. PayPal or Print and Mail) Will mail in payment. Will use PayPal. Using PayPal on next screen Mailing dues
Comments: Type comments here.
Submit will send an E-mail of this form to the AZCB.