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.):
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________