IVIE

Independent Visually Impaired Entrepreneurs

An Affiliate of the American Council of the Blind

Member of
American Council of the Blind, Together for a bright future
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Membership Application

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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:

If different from your business address, please fill in personal information below:
Personal Street Address:
City:   State:   Zip:
Phone:

Gender
Female     I Identify as a Female     Male     I Identify as a Male     Nonbinary    
Other - I prefer not to answer

Race/ethnicity
Asian    Black or African American    Hispanic or Latino    Middle Eastern or North African     Multiracial or Multiethnic    Native American or Alaska Native     South Asian    White Anglo/Caucasian    Other

Do you wish your email address to be put on the IVIE website?  
(Emails are displayed for people to see, but are hidden from 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 Digital Cartridge, enter Yes   
If Email,  enter Yes    If Large Print, enter Yes

Membership Amount: $15.00
If you wish to include your booth price, add $10.00

If you wish to mail this application with your check, print this page first using the print button below and then click the SUBMIT button. Make out your check to "IVIE" and send both application and check to

IVIE
%Ardis Bazyn, President
2121 Scott Road #105
Burbank, CA 91504

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

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For more information, contact President Ardis Bazyn (818) 238-9321
or email:

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