ACBNY Membership Application - Paypal
ACBNY Membership Application - Paypal
Name
Name
First
Last
(Optional) Organization Name:
Address
Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
United States
United Kingdom
Canada
Australia
Netherlands
France
Germany
-------
Afghanistan
Albania
Algeria
Andorra
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Argentina
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Bangladesh
Barbados
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Belize
Benin
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Bhutan
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Chile
China
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Finland
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Gambia
Georgia
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Iran
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Japan
Jersey
Jordan
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Kenya
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Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
New Zealand
Nicaragua
Niger
Nigeria
Norway
North Korea
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Telephone
Email
Gender
Gender
Female
I identify as female
Male
I identify as male
Nonbinary
Other
I prefer not to answer
Race / ethnicity
Race / ethnicity
Asian
Black or African American
Hispanic or Latino
Middle Eastern or North African
Multiracial or Multiethnic
Native American or Alaska Native
Other
South Asian
White - Anglo/Caucasian
Extent of visual impairment:(Choose one)
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)
ACB Braille Forum: (Choose one)
E-Mail
Braille
Digital Cartridge
Large Print
ACBNY Insight Newsletter: (Choose one)
ACBNY Insight Newsletter: (Choose one)
Email
Large Print
Membership Type
Membership Type
Regular Membership
At-Large Membership
Which ACBNY affiliate/chapter would you like to joinn or update?
ACBNY Affiliate or Chapter: (Choose one)
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)
RSVNY (Randolph Shepherd Vendors)
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. Not sure? Contact our membership chair: membership@acbny.info At-Large and Organizational members should send their dues to the ACBNY Treasurer.
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