Membership Form
Mississippi Council of the Blind

Name:

Address:

City: State: Zip:

Telephone: E-mail:

Periscope Format: Large Print Email NLS Cartridge Computer CD

Braille Forum Format: Large Print Email NLS Cartridge

Chapter Affiliation:

Birthday: Month   Day   Year

Date of Joining:

Fully Sighted? Yes   No

If making payment by check, make check payable to Mississippi Council of the Blind
and mail check to:
Rene Virden – Treasurer
P. O. Box 134
Clinton, MS 39060

MCB STATE DUES: $10

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