Deaf-Blind League of NJ

2010 Membership Form

New______        Renewal_____

(PLEASE PRINT)


NAME:

ADDRESS:

HOME PHONE #:

WORK PHONE #:

E-MAIL ADDRESS:

DEAF________            H/H___________      HEARING__________

BLIND_______           SIGHTED__________

ANNUALLY, A PRINTED DIRECTORY GOES OUT TO MEMBERS. PLEASE SELECT THE CONTACT INFORMATION YOU WANT IN THE PRINTED DIRECTORY.

___ NAME

___ MAILING ADDRESS

___ HOME PHONE NUMBER

___ EMAIL ADDRESS

 

MEMBERSHIP DUES: $35.00 COUPLE (HUSBAND/WIFE)


                                        $20.00 SINGLE

SEND MEMBERSHIP FORM WITH A CHECK PAYABLE TO DBLNJ   TO: JULIE TROGER


27 BRADFORD LANE, PLAINSBORO NJ 08536

THANK YOU FOR YOUR SUPPORT!