Membership Form

Business Name

Business type: (What you do - not all business names are intuitive)

Business Street Address:

City/State/Zip Code:

Business Phone (xxx-xxx-xxxx):

Business Email:

Business website:

If you wish to offer discounts to other members or first-time customers, please specify your discount here:

PERSONAL INFORMATION: Name (First, Last) *

First

Last

Address:

City/State/Zip Code

Home Phone: {xxx-xxx-xxxx)

Personal Email Address: *

Email

Confirm Email

Check here if you do not want your email address on the IVIE website. (Email addresses are encrypted so spammers do not have access to it.)

Gender (Please Check One)

Race/ethnicity (Please Check One)

Chose which format you would like to receive the ACB Monthly Braille Forum Publication