BVA MEMBERSHIP APPLICATION OR RENEWAL FORM
Blinded Veterans Association
477 H Street, Northwest,Washington, D.C. 20001-2694
(202) 371-8880 or (800) 669-7079

(please print)
Name: ________________________________________ Date: _________
Address: _____________________________________________________
City: _________________________ State: ______ Zip: ________________
Telephone No.: (     ) _____________________ 
Date of Birth: ___________________Social Security No.: ______________
VA Claim No.: ________________________
I served in: __ World War II,  __ Korean,
__ Vietnam,  ___ Persian Gulf, or __ Peacetime

The Department of Veterans Affairs (VA) has rated my blindness as
(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 rate.
__ $80.00 44 years or younger 		__$50.00 61 years - 65 years
__ $70.00 45 years - 54 years 		__$40.00 66 years and older
__ $60.00 55 years - 60 years

__ PAYING TO LIFE OR ASSOCIATE LIFE MEMBER. Requires a $10.00 initial
payment. I will pay the balance of my Life/Associate Life Membership
rate within two years.

If paying by credit card, please provide the following information:
__ VISA __ MASTERCARD Amount $____________________________
Card Number ______________________________________________ Expires ___________________________________________________
Name (please print) _________________________________________
Card Holder's Signature ______________________________________