BAY STATE COUNCIL OF THE BLIND
                     MEMBERSHIP APPLICATION
 
 
Name:
 
Home address:
 
Home phone:
 
Occupation:
Business phone:
 
E-mail address:
 
Extent of visual impairment:
     ---- Totally blind
     ---- Partially sighted
     ---- Sighted
 
Please indicate your preference for receiving
organizational correspondence:
     ---- large print 
     ---- cassette
     ---- braille
     ---- E-mail
 
Committee interests:
     ---- Fund-raising
     ---- Arts & leisure 
     ---- Transportation concerns
     ---- Employment concerns
     ---- Public education
     ---- Newsletter
     ---- Membership
     ---- Legislative
 
Signature:  ---------------
Date:  
 
 
Send your application for membership at large, along with your
check for
$12.00 to:
 
Rick Morin
58 Helen Street
Waltham, MA 02452