Member At Large Application

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Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email

Occupation

Birthdate (MM/DD/YY)

Vision (Sighted, Blind, Legally Blind)

Recommended By

Reason for Joining

Correspondence Format Preferred (Braille, Large Print, Email, Print)

Each member is eligible to receive The Missouri Chronicle; a quarterly publication providing news about MCB and its members and activities. The Chronicle is available on our web site at www.moblind.org. If you prefer to have it mailed to you, please make your format selection below. Choose from the following: Large Print, Braille, E-mail or Digital Cartridge

Chronicle Format Preference

All applications must be accompanied by one year's dues of $20.00. Send Application and dues to

Missouri Council of the Blind,
5453 Chippewa, St. Louis, MO 63109.

Please allow 30 days for Committee Approval.

Applicant Signature and Date

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