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New Jersey Council of the Blind
An affiliate of
American Council of the Blind
MEMBERSHIP AT LARGE
APPLICATION

Name: ______________________________________________________

Street: ______________________________________________________

City: ________________________________________________________

State: ______________________Zip: _____________________________
 

Phone Number: _______________________________________________
 

E-Mail Address: ______________________________________________
 

Legally Blind: ____ Visually Impaired: ____ Fully Sighted: ____

Format for Braille Forum (ACB National's Newsletter): LP __ Half Speed Cassette __ Braille __ E-mail __

Format for NJCB Chronicle: E-Mail _____Online _____

Annual Dues: $10.00 due in January

Make check payable to NJCB and send to:
Treasurer- Bernie Zuckerman
32 Judson St. Unit 7-B
Edison, NJ 08837
(732) 221-5362

President- Lauren Casey
(609) 912-0657