Of the Blind and Visually Impaired

Association for Education and Rehabilitation of the Blind and Visually Impaired 1703 N. Beauregard St., Suite 440 ▪ Alexandria, VA 22311-1744 USA (877) 492-2708 ▪ (703) 671-4500 ▪ Fax (703) 671-6391 ▪ [email protected] ▪ www.aerbvi.org Membership Renewal / Other Payments To renew, complete this form and mail with your check to: AER Membership Renewal at above address. If paying by credit card, pay online at www.aerbvi.org, or fax to (703) 671-6391, or call (877) 492-2708 or (703) 671-4500. Member type Dues (Funds shown in U.S. dollars) Date  Regular/International $167  Quarterly Payments* $ 43 Member ID  Same Residential Household $140  Retired $ 90  Support/Clerical $ 90 Name  Student $ 90 Organization  Transition $136  Associate $ 90 Primary Occupation Division Dues (Check all you wish to join)  Administration $ 10 Preferred address below is Work  Home   Rehabilitation Counseling, Employment and BEP Services $ 10 $ 10 Address  Multiple Disabilities & Deafblind $ 10  Psychosocial Services $ 10 City, State/Province  Information & Technology $ 10  Low Vision Rehabilitation $ 10  Infant & Preschool $ 10 Zip/Postal Code/Country  Orientation & Mobility $ 10  Education Curriculum $ 10 Phone  Vision Rehabilitation Therapy $ 10  Division on Aging $ 10  Itinerant Personnel $ 10 Fax  Personnel Preparation $ 15

Total for my membership (Dues + Div.) $ ____ E-mail  Other ______$_____  Job Exchange Member or Non Member $49 or $149 Web site *A quarterly payment option for a one-year membership is available to Regular and International Members by calling the office during regular business hours.  Check enclosed made payable to AER for $ _(Funds in U.S. dollars for checks and charges)  Charge: Visa $  MasterCard $  Discover $  American Express $ Card Number Exp. Date CSC Code Cardholder Name (please print) Cardholder Address Signature

RenewalApp01-13 OFFICE USE: Date Rec’d. By Noah Batch

RenewalApp01-13