ACBNY Membership Application

Name:
First Name:
Last Name:

(Optional) Organization Name:

Address:

City:
State:
Zip Code:

Telephone:

E-Mail Address:

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)
E-Mail
Braille
Cassette
Large Print

ACBNY Insight Newsletter: (Choose one)

E-Mail
None, Thanks

Local Meeting Notice:(Choose one)
E-Mail
Large Print
Braille

Membership Type
Working Member
Non-Working Member
Life Member
Junior Member
Associate Member
Organizational Member

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)
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. At-Large and Organizational members should send their dues to the ACBNY Treasurer.