Arizona Council of the blind LOGO.  A Yellow Sun behind Green Cactus the letters A Z C B on the sun.

Arizona Council of the Blind, INC. f
3124 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
New Member

TODAY'S DATE (MM/DD/YYYY):

BIRTHDAY (MM/DD/YYYY):

$10.00 Dues for the Arizona Council (AzCB plus any Affiliates.


AzCB $10.00

Maricopa Club $3.00

Phoenix Chapter $5.00

Southern Arizona Council $5.00

Guide Dog Users of Arizona $10.00

Total all the boxes checked and put amount here ($10.00 just the State Membership to $33.00 for all the Affiliates)

Name:
Address Line 1:
Adress Line 2:
City:
State/Province:
ZIP Code/Postal Code:
Telephone:
Phone NUMBER: Full Phone Number including area code.

Email Address:

OCCUPATION:

Vision - CHECK ONE:

NEWSLETTER PREFERENCE for Fore-Sight (newsletter of the Arizona Council) Check one:

ACB BRAILLE FORUM (newsletter for NATIONAL) check one:

How did you hear about AzCB?

If other please tell us how?

Method of payment (i.e. PayPal or Print and Mail) Using PayPal on next screen
Mailing dues

Comments:

Submit will send an E-mail of this form to the AZCB.

Return to AzCB Web Site