BVA MEMBERSHIP APPLICATION Or. RENEWAL FORM (Marg)   
Blinded Veterans Association

477 H Street, Northwest, Washington, D.C. 20001-2694
(202) 371-8880 or (800) 669-7079

(please print)

Name: ___________________________________

Address: _________________________________

City: _____________________________________

Date :

State:

Zip:

Telephone No.: (     )
Date of Birth:

Social Security No.:
VA Claim No.: _____________________________
I served in: __Vietnam, ___World War I, __ World War II, __Korean,

___Persian Gulf, or __ Peacetime

The Department of Veterans Affairs (VA) has rated my blindness
(you must check one of the following) :                                            
__ SERVICE CONNECTED  __ NON-SERVICE CONNECTED

I would like to become a:                                                               

______ MEMBER/ASSOCIATE MEMBER, ($8.00 annual dues)     

______ LIFE MEMBER/ASSOCIATE LIFE MEMBER.

 I qualify for the following

__ $80.00 44 years or younger                       ___$50.00 61 years- 65years

__ $70.00 45 years - 54 years                        ___$40.00 66 years and

__ $60.00 55 years - 60 years

_____ PAYING TO LIFE OR ASSOCIATE LIFE MEMBER.

Requires a $10.00 payment. I will pay the balance of my Life/Associate Life

Members rate within two years.

If paying by credit card, please provide the following information

__VISA __MASTERCARD Amount $_____

Card Number _____________________________

Name (please print) ________________________

Card Holder's Signature_____________________