American Association of the Deaf-Blind
MEMBERSHIP APPLICATION

(check one)

__New
__Renew__New Address

Today's Date:Name:
Address 1:
Address 2:
City:
State:
Zip:
Email:
Phone Number and type:_
Membership Type: (Select one):

__Active (deaf-blind & permanent USA resident - $15/year
)__Associate (USA non-deaf-blind supporter - 
$15/year
)__International (
$15/year)
__Organization (Non-Profit - $50/year)
__

Organization (For Profit - $75/year)

AADB Today: (Please select which format you want):

__Email (please select email format: plain text__  html__


__Regular Print


__Large Print (18 point bold)
__Braille (Grade 2)
__CD (PDF, MSWord and Plain Text)SSP Services:  I would like to have Support Service Provider (SSP) services in my area when AADB sets up nationwide SSP services for deaf-blind members:  

__Yes
__

No

Membership Dues 
$

Tax-deductible donation – THANK YOU!
$

Total:
$
_____
Payment type (Please select one payment type):

__Credit Card
__Check or Money Order
If paying by credit card:
What type:
__Visa


__MasterCard
__AMEX
__Discovery

Card Number:
Expired Date Month/Year (xx/xxxx):If the credit card 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!

You can also fax your membership application with your credit card to AADB at (301) 495-4404.

Please mail your application along with your payment to:

AADB
8630 Fenton Street, Suite 121
Silver Spring, MD 20910

For membership benefits, go to AADB’s website at www.aadb.org or contact the AADB Office at (301) 495-4402 (TTY/VP), (301) 495-4403 (Voice), or (301) 495-4404 (Fax).


 For Office Use Only
Received: Date____________$________.____ Acknowledged: Date_______________ Exp. __________
Revision: August 2010

Revision: February 2011