Arizona Council of the Blind, INC.
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 print or 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, $0.00 Guide Dog Users of Arizona.

Is this a renewal or a new member application? (Check one): New Member
Renewal

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 Group $5.00
Southern Arizona Council $5.00
Guide Dog Users of Arizona $0.00

Total all the boxes checked and put amount here ($10.00 to $23.00)

Check one:
Mrs. Mss Miss
Mister

Name:
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City:
State/Province:
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Phone AREA CODE:
Phone NUMBER:

Email Address:

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 LABEL FOR="adonot">Do Not Send Arizona Newsletter Do not send.>

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

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