MEMBERSHIP APPLICATION

You may either print this application and mail it in with your check, or you may send it by email and pay on your card immediately. First, fill out this application online. At the bottom, if you wish to print it, click the PRINT. If you wish to send it by email and pay by card, click the SUBMIT link. If you wish to do both, that is, print it to have a copy for your records but also pay it by card, then click the PRINT link first and then click the SUBMIT link afterwards.

Year First Joined: New Member Renewal

Name:

Address:

City: State: Zip:

Home Phone: Fax: E-mail:

Business

Business Name:

Work Address:

Work City: Work State: Work Zip:

Work Phone: Cell: E-mail:

Membership

Regular Member**	Dues $10.00 Any legally blind person who manages or is an employee in a facility.
Associate Member**	Dues $10.00 Any Interested person, business or organization wishing to support the aims and goals of R.S.V.A.
Life Member**	Free, retired, 5yr. member nominated by state affiliate. Or any member in good standing wishing to become a Life member for a one time donation of $1000.00
Corporate Member**	Any business or organization wishing to support the goals of R.S.V.A. Please contact the national office for details.

Member Profile

Vendor Administrator Spouse Employee Other
Other:

Blind Partial Sighted

Vendorscope

Large Print Duplicate Cassette E-mail

Braille Forum

Large Print Braille Cassette Disk

Donations

**Randolph-Sheppard Vendors of America:

**Durward K. McDaniel Memorial Fund (A legacy of legal support):

**You will be able to pay by Credit Card or your PayPal account after you submit your registration form.

If mailing application, make check payable to R.S.V.A. Treasurer
Mail application with check to:
Kim Venable, Treasurer
940 Parc Helene Drive
Marrero, LA 70072-2421
Phone: 1-504-328-6373

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