American Association of the Deaf-Blind


MEMBERSHIP APPLICATION


     New        Renew  (      New Address?)   Date: _________
Name: 	
Address: 	
City/State/Zip: 	
Home Phone: 			Voice:  TTY:  VP
Work Phone: 			Voice:  TTY:  VP
Email: 
Fax: 
Check ONE:  Membership Type
___Active (deaf-blind & permanent USA resident) $10/year
___Associate (USA non-deaf-blind supporter) $10/year
___International	USD $10/year
___Organization (Non Profit)	$50/year
___Organization (For Profit) $75/year

The DBA Magazine and AADB E-News: In what format do you want (Select one)
(Organizations select two)
___Regular Print 		
___Large Print (18-pt. bold)				 
___Braille (Gr. 2)
___Disk (MSWord and Text)
___CD (PDF, MSWord and Text)

If prefer email, please select one media preference:
PDF: Large Print__  Regular Print__
MS Word: Large Print__  Regular Print__
Plain Text: As an attachment__  In the email__
		
How did you hear about us?
Friend’s Name _________________Other _______________

Membership Fee $_________
Tax-deductible donation – THANK YOU! $_________
Total: $________

For credit card payment and other information, please check the next page.

Please make check or money order payable to AADB and send along with this form to:	
AADB
8630 Fenton Street, Suite 121
Silver Spring, MD  20910-3803


AADB IS THE ONLY NATIONAL ORGANIZATION
OF, BY AND FOR DEAF-BLIND AMERICANS
THANK YOU FOR SUPPORTING AADB!

 
For Office Use Only
Received: Date____________$________.____ 
Acknowledged: Date_______________ Exp. __________

AADB October 2007


TO PAY BY CREDIT CARD* (Visa or MasterCard only)*:
Do not email credit card information!

Card Type:  ___Visa        ___MasterCard
Card Number: ______________________________________
Expiration Date:  Month/Year _____/_____
Name (as on card): __________________________________
Signature: _________________________________________
Billing Address (if different from other side)
Street: ____________________________________________
City/State/Zip: ______________________________________
Home Phone Number: _______________________________

*If you pay by credit card, you may fax your membership form and credit card info to AADB at (301) 495-4404.

For membership benefits, go to AADB’s website at www.aadb.org or contact the AADB Office at (301) 495-4402 (TTY/VP), (301) 495-4403 (Voice), or (301) 495-4404 (Fax).