Silicon Valley Council of the Blind
Membership Application and Instructions
rev. 10/6/09

Instructions

Send this form (filled out) and a check for the appropriate membership dues (listed at the bottom of this application) to:

Silicon Valley Council of the Blind
P. O. Box 493
Mountain View, CA 94042-0493

Please do not mail cash. Your check will serve as your receipt.

You may also email this form, if the dues were paid separately.

For more information about SVCB and the great benefits of membership, please email membership@svcb.cc. In addition, use this address to request application forms in large print and braille.

SVCB Membership Application Form

NAME:

STREET ADDRESS:

CITY:

STATE:

ZIP CODE:

HOME PHONE:

WORK PHONE:

CELL PHONE (if you want it published):

EMAIL ADDRESS:

BIRTHDAY (month, day, optional year):

OCCUPATION:

SPECIAL INTERESTS:

ARE YOU TOTALLY BLIND? (Y/N):

ARE YOU LEGALLY BLIND? (Y/N):

ARE YOU PRINT-HANDICAPPED AND NOT LEGALLY BLIND? (Y/N):

SELF-DESCRIPTION OF YOUR VISION STATUS (legally blind/visually impaired/fully sighted):

PREFERRED FORMAT FOR EACH PUBLICATION

Possible formats: Braille/cassette tape/diskette/email/large print

SVCB IN TOUCH Newsletter (monthly):
Blind Californian (quarterly):
Braille Forum (almost monthly):

PHONE TREE

Do you want to be contacted once a month about the next meeting and about late-breaking news items? (Y/N):

If YES, by phone or by email? (P/E):

If by email, at what address?

Do you currently belong to any other chapter of the California Council of the Blind? (Y/N):

Have you ever been a member of SVCB before? (Y/N):

Are you currently receiving the Blind Californian or Braille Forum? (Y/N):

If so, which?

FOR OFFICIAL USE ONLY

Date dues paid:
Amount:
Method of payment (check, cash):
Received by:
For year(s):
Other comments:

Dues are $10/calendar year with the following exceptions:
$7/year for members for whom SVCB is not their home chapter (for example, people whose home chapter is the San Mateo chapter); the other chapter pays dues to CCB, we don't.
$7 for life members of CCB.
$13 for a two-year membership initiated July 1-December 31 (that is, for the remainder of the current year plus all of the next one) by a NEW member. Rejoining members cannot do this.