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ACBNY Membership Application

Name:
First Name: Last Name:
(Optional) Organization Name:
Address:
City: State: Zip Code:
Telephone:
E-Mail Address:

Extent of visual impairment:(Choose one)
Totally Blind Partially Sighted Sighted

Please indicate your preference for receiving ACBNY organizational correspondence

ACB Braille Forum: (Choose one)
E-Mail Braille Cassette Large Print

ACBNY Insight Newsletter: (Choose one)
E-Mail None, Thanks

Local Meeting Notice:(Choose one)
E-Mail Large Print Braille

Membership Type Working Member Non-Working Member Life Member Junior Member Associate Member Organizational Member

Which ACBNY affiliate/chapter would you like to joinn or update?

ACBNY Affiliate or Chapter: (Choose one)
Capital District (Albany Area) Greater New York Council of the Blind (NYC Area) Guide Dog Users of the Empire State (GDUES) Long Island Council of the Blind New york State Council of Citizens with low Vision (NYSCCLV) Rochester Council of the Blind Utica Council of the Blind Westchester Council of the Blind ACB of Western New York (Buffalo area) At Large Membership in ACBNY without local affiliation Organizational Member I Don't Know; Please Contact me with more information

Please contact your local or special interest affiliate to determine what your annual dues will be and where to send them. At-Large and Organizational members should send their dues to the ACBNY Treasurer.

Print out or save this Application for your records.


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