SOUTH CENTRAL KENTUCKY COUNCIL OF THE BLIND

MEMBERSHIP FORM

Complete the information form below and press the Paypal Buy Now button and your application will be forwarded to the Treasurer of the SCKCB. You will be redirected to Paypal's site to verify your information with Paypal to pay your annual dues of $10.00.

You may also print this form out with the print button and send it along with your annual membership dues of only $10, check or cash, payable to SCKCB. Our mailing address is as follows:

SCKCB
Attention: Treasurer
1652 Media Drive
Bowling Green, KY 42101

Application Type

New Membership or Renewal? New Membership Renewal

Name

First:

Last:

Address

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Braille Forum

In what format would you like to receive your copy of the Braille Forum, our flagship publication?

Visual Acuity

What is your visual status?

Contact Information

Your email address:

Your phone number: