MEMBERSHIP FORM

Please print this form, fill it out, and send along with your $8.00 dues
(or $40 for a Life Membership) to:

Carla Ruschival, Treasurer
Kentucky Council of the Blind
148 Vernon Avenue
Louisville KY, 40206

NAME:___________________________________________________

MAILING ADDRESS:________________________________________________


CITY: ________________________ STATE: _____ ZIP: __________


E-MAIL ADDRESS:______________________________


PERSONAL WEB SITE:___________________________


COMPUTER: ____________ SCREENREADER: ____________


BRAILLE DEVICE: _________________________


OPERATING SYSTEM: ______________________


COMMENT:_______________________________________________


ENCLOSED IS MY $8.00 (or $40.00 for a Life Membership)

_____CASH, _____CHECK, or _____MONEY ORDER

REPRESENTING MY PAID MEMBERSHIP IN FULL FOR THE KENTUCKY COUNCIL OF THE BLIND (KCB)

I UNDERSTAND THIS ENTITLES ME TO ALL OF THE RIGHTS AND PRIVILEGES ACCORDED ANY OTHER FULLY PAID KCB MEMBER.

NOTE: Memberships are not prorated and all current memberships terminate and must be renewed on the date of the Annual Meeting of the State Convention.