* = required area to complete on the form * First Name: Middle Initial: * Last Name:
Address:
City: State: Zip Code:
* Home Phone:
Work Phone:
* E-Mail Address:
Vision: Select your amount of vision Blind Low Vision Sighted
Format for White Cane Bulletin: Select Format Cassette Large Print Braille E-Mail
Format for Braille Forum: Select Format Cassette Large Print Braille E-Mail
Chapter/Special Affiliate Name and Number: If completing as a Member-At-Large, hit "M" once on the keyboard Member-At-Large - 70 Alachua - 15 Brevard - 4 Clay - 10 Dolly Burck Gold Coast - 67 Florida Coalition for the Concerns of the Totally Blind - 101 Florida Coalition of Blind Students - 58 Florida Council of Citizens with Low Vision - 60 Greater Miami - 16 Halifax - 18 Inter-County (Ocala) - 14 Jacksonville - 22 Miami-Metro - 28 Mid-Florida Council of the Blind - 30 Palm Beach - 24 Pensacola - 35 Pinellas - 33 Port St. Lucie - 50 Randolph-Sheppard Vendors of Florida - 64 Sarasota - 42 Southwest Council of the Blind - 71 Tallahassee - 44 Tampa - 45 Venice - 32
Are you a patron of the Talking Book Library? Select Yes or No Yes No
Are you a Chapter or State Officer? Choose Yes or No Yes No
Sex: Select Gender Male Female
Date of Birth:
Thank You for your interest in and support of Florida Council of the Blind. Please hit "CTRL + P" on your keyboard to print out the completed form. If you are a current member of a Chapter/Special Affiliate or are completing this form to become a member of a Chapter/Special Affiliate, please contact your local Membership Secretary and arrange for payment of your dues. If you have filled this form out as a "Member-At-Large," please send this form with your check or money order for $10.00 to: SALLY BENJAMIN FCB MEMBERSHIP SECRETARY 1531 Dempsey Mayo Road Tallahassee, FL 32308 Please make your check or money order payable to FCB. Thanks again for your interest in and support of Florida Council of the Blind.
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