Silicon Valley Council of the Blind

 

SVCB Membership Application Form and Instructions

rev. 11/12/19 (New dues amount)

 

Instructions: Complete the application form that follows and submit it along with the appropriate dues (see below) to: 

 

Silicon Valley Council of the Blind 

P.O. Box 493, Mountain View, CA 94042-0493 

 

Cash should not be used unless hand-delivered to the membership chairperson.

 

Dues: $20 per calendar year with the following exceptions: 

 

Note: Multiple years dues can be paid at any time.

 


 

Thank you for wanting to become a member of SVCB.

 

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

 

TITLE: _______     

NAME: ______________________________

STREET ADDRESS: 

____________________________________

CITY: ___________________ 

STATE: ____ ZIP CODE: _________

 

PRIMARY PHONE: __________                         

ALTERNATE PHONE: __________

 

EMAIL ADDRESS: ___________________________________

 

Can your information be published (Y/N)? ____________

BIRTHDAY (MONTH; DAY; optional YEAR): _______________

 

VISION STATUS:

(LEGALLY BLIND, VISUALLY IMPAIRED, FULLY SIGHTED, PRINT HANDICAPPED) __________________________________



PUBLICATIONS FORMAT:

(BRAILLE, EMAIL, LARGE PRINT, CASSETTE

SVCB IN TOUCH: ____      

BLIND CALIFORNIAN: ____    

BRAILLE FORUM: ____

 

 

MEETING REMINDER:

Do you want to be contacted monthly about the meeting and news items (Y/N)?  _____ 

If ‘Yes’ provide a phone number and/or email address as needed:

____________________________

 

OTHER CCB CHAPTER MEMBERSHIP:

If you currently belong to any other chapter of the California Council of the Blind, give the chapter name: 

_______________________________

MISCELLANEOUS: (OCCUPATION, SPECIAL INTERESTS, ORGANIZATIONS, etc.): 

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________