Your Name (First Name: Middle Initial: Last Name:) * (Last Name, Middle Initial, First Name) Address * City * State * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code * Home Phone * Cell Phone E-Mail Address * Vision: * Blind Low Vision Sighted Format for White Cane Bulletin Print Audio Large Print Braille Email Format for Braille Forum Digital Cartridge Large Print Braille Email Podcast Chapter/Special Affiliate Name and Number * - Select -Member At Large - 70Braille Revival League of Florida - 75Chapter At Large Members - 78Coalition for the Concerns of the Totally Blind - 101Florida Council of Citizens with Low Vision - 60Greater Miami Council of the Blind - 16Greater Orlando Council of the Blind - 30Guide Dog Users of Florida - 102Halifax Council of the Blind - 18Jacksonville Council of the Blind - 22Manatee Council of the Blind - 74Miami Beach Council of the Blind - 73Miami-Metro Council of the Blind - 28Northwest Florida Chapter of the Florida Council of the Blind - 35Palm Beach Council of the Blind - 24Pinellas Council of the Blind - 33Randolph-Sheppard Vendors of Florida - 64Sarasota Chapter of the Florida Council of the Blind - 42Southwest Florida Council of the Blind - 71Tallahassee Council of the Blind - 44Tampa Council of the Blind - 45 Secondary Chapter/Special Affiliate Name and Number - None -Member At Large - 70Braille Revival League of Florida - 75Chapter At Large Members - 78Coalition for the Concerns of the Totally Blind - 101Florida Council of Citizens with Low Vision - 60Greater Miami Council of the Blind - 16Greater Orlando Council of the Blind - 30Guide Dog Users of Florida - 102Halifax Council of the Blind - 18Jacksonville Council of the Blind - 22Manatee Council of the Blind - 74Miami Beach Council of the Blind - 73Miami-Metro Council of the Blind - 28Northwest Florida Chapter of the Florida Council of the Blind - 35Palm Beach Council of the Blind - 24Pinellas Council of the Blind - 33Randolph-Sheppard Vendors of Florida - 64Sarasota Chapter of the Florida Council of the Blind - 42Southwest Florida Council of the Blind - 71Tallahassee Council of the Blind - 44Tampa Council of the Blind - 45 Are you a patron of the Talking Book Library? Yes No Are you a Chapter or State Officer? Yes No Date of Birth Gender * - Select -I identify as a femaleI identify as a malenonbinaryotherI prefer not to answer Race or Ethnicity
