ACBNY Membership Application - Pay By Check

Name Name First Last
(Optional) Organization Name:
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
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.
Please send your payment to ACBNY treasurer Rosanna Beaudrie ACBNY 8 Hemlock Lane Levittown NY 11756 For questions contact treasurer@acbny.info or call 914.631.4870
$0

Total

ACBNY Membership Application - Pay By Check

ACBNY Membership Application - Pay By Check

Please indicate your preference for receiving ACBNY organizational correspondence

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.

Please send your payment to ACBNY treasurer Rosanna Beaudrie ACBNY 8 Hemlock Lane Levittown NY 11756 For questions contact treasurer@acbny.info or call 914.631.4870

$0

Total

Please indicate your preference for receiving ACBNY organizational
correspondence

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