American Association of the Deaf-Blind 8630 Fenton Street, Suite 121 Silver Spring, MD 20910-3803 MEMBERSHIP APPLICATION(__) New (__) Renew (__) New Address Date: __/__/__ Name: _______________________________________ Address 1: _______________________________________ Address 2: _______________________________________ City: __________________ State: ____ Zip: _______ Email: _______________________________________ Phone: ________________ VP: ___ TTY: ___ Voice: ___ Mobile Phone/Text: _________________ Membership Type: (Check One) ACTIVE (deaf-blind & permanent USA resident) ___ 1 year - $15.00 ___ 2 years – $25.00 ___ 3 years - $30.00 ASSOCIATE (non-deaf-blind supporter & USA resident) ___ 1 year - $15.00 ___ 2 years – $25.00 ___ 3 years - $30.00 INTERNATIONAL ___ 1 year - $30.00 ___ 2 years – $50.00 ___ 3 years - $60.00 ORGANIZATION (Non-Profit) ___ 1 year - $75.00 ___ 2 years–$125.00 ___ 3 years -$150.00 ORGANIZATION (For-Profit) ___ 1 year - $125.00 ___ 2 years–$200.00 ___ 3 years -$300.00 LIFETIME Individual ___ Deaf-Blind - $500.00 ___ Non Deaf-Blind – $500.00 Organization ___ Non-Profit - $1875.00 ___ For Profit – $2500.00 AADB Today: ___ Email (please select) ___ Plain Text, or ___ HTML ___ Regular Print ___ Large Print (18 point bold) ___ Braille (Uncontracted - Grade 2) ___ CD (PDF, MS Word, Plain Text) ___ Other (Please specify): ___________________________ Payment: Membership Dues $ _________ Tax-deductible donation – THANK YOU! $ _________ Total: $ _________ Payment type: _____ Credit Card _____ Check or Money Order If paying by credit card: ___ Visa ___ MasterCard ___ AMEX ___ Discover Card Number: _________________________________________ Expiration Month/Year (xx/xxxx): _________________________ CVV Verification Code: ______ (For Visa, MC and Discover this is a 3-digit number on the back of the card. For AMEX this is a 4-digit number on the front of the card.) If the credit card billing information is not the same as above, please fill in this section: Name (as on the card): ______________________________________ Billing Address: ______________________________________ City/State/Zip: ______________________________________ Phone Number: ______________________________________ Do NOT email credit card information! Please mail this application along with your payment to: AADB 8630 Fenton Street, Suite 121 Silver Spring, MD 20910-3803 301-563-9107 (Video Phone) ? 301-495-4403 (Voice) 301-495-4404 (Fax) ? Email: AADB-Info@aadb.org ? Website: www.aadb.org