Print and mail this application form with your check, or submit this form to email and send your check separately.

First Name:    Last Name:

Business Name:
Website:    http://
Business Type:  
(What you do - not all business types are intuitive)

Business Street Address:
City:   State:   Zip:
Phone:

Email Address:

Personal Street Address:
City:   State:   Zip:
Phone:

Do you wish your email address to be put on the IVIE website?  
(Emails are hidden so they cannot be picked up by spammers)
Enter Yes or No

Do you offer discounts to IVIE members or first time customers?
If Yes, describe the discount here:

Select the Formats you want for the Braille Forum:
If Braille, enter Yes    If Cassette, enter Yes    If Large Print, enter Yes
If Email,  enter Yes    If Disk, enter Yes

Caution: if you want a printed version of this page and also email it, you must print it first and submit it second.