Independent Visually Impaired Entrepreneurs

An Affiliate of the American Council of the Blind

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Membership Application

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Print and mail this application form with your check, or submit this form to email and send your check separately.

First Name:    Last Name:

Business Name:
Website:    http://
Business Type:  
(What you do - not all business types are intuitive)

Business Street Address:
City:   State:   Zip:
Phone:

Email Address:

Personal Street Address:
City:   State:   Zip:
Phone:

Do you wish your email address to be put on the IVIE website?  
(Emails are displayed for people to see, but are hidden from spammers.)
Enter Yes or No

Do you offer discounts to IVIE members or first time customers?
If Yes, describe the discount here:

Select the Formats you want for the Braille Forum:
If Braille, enter Yes    If Cassette, enter Yes    If Large Print, enter Yes
If Email,  enter Yes    If Disk, enter Yes

Membership Amount: $15.00
If you wish to include your booth price, add $10.00

If you wish to postal mail this application with your check, do NOT click the SUBMIT button below,
but instead, print this page using the PRINT button below, make out your check to "IVIE"
and send both application and check to

IVIE
%Ardis Bazyn, President
2121 Scott Road #105
Burbank, CA 91504

Press this SUBMIT button only if you want to email your application and pay by card.
Note: if you want a printed version of this page and also email it, you must print it first and submit it second.

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For more information, contact President Ardis Bazyn (818) 238-9321
or email:

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