APPLICATION FOR MEMBER AT LARGE



Being desirous of becoming a member of the organized blind movement, I hereby make application to the Missouri Council of the Blind. I hereby pledge my allegiance to its policies and programs.

(Application must be accompanied by one year's dues: $10.00)

NAME: ___________________________________________________

ADDRESS: __________________________________________________

CITY: _______________STATE: ________ZIP:________

TELEPHONE: (____) _______________________________

OCCUPATION: _______________________________________________

AGE: ____________

LEGALLY BLIND: _________ SIGHTED: ______________

RECOMMENDED BY: __________________________________________

REASON FOR JOINING: ________________________________________

MEMBER OF OTHER BLIND CONSUMER ORGANIZATIONS: (yes; no; if yes, give name) ___________________________

REMARKS: ___________________________________________________

Would you like THE MISSOURI CHRONICLE, our quarterly publication?

YES _______ NO _____­

IF YES, IN WHICH FORMAT:

BRAILLE: _____ LARGE PRINT: _______

CASSETTE: __________

E-MAIL: _________ E-MAIL ADDRESS: __________________________

DATE OF APPLICATION APPROVED BY MCB EXECUTIVE BOARD:

_________________

SIGNATURE OF EXECUTIVE DIRECTOR:

_______________________________________________

PLEASE MAIL APPLICATION, ALONG WITH DUES, TO:

MISSOURI COUNCIL OF THE BLIND
5453 CHIPPEWA
ST LOUIS, MO 63109

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