Application And Renewal Form

Submitted by rmann on Thu, 05/10/2018 - 19:35

Membership is for the Calendar Year, January 1 to December 31. All dues received after 9/1/2017 will be applied to the remainder of 2017 and the calendar year 2018. Please complete this form and return it along with your check to: Friends of Library Access, Inc. P.O. Box 10716 Daytona Beach, FL 32120-0716

Today's Date: ________________________________________
Last Name ________________ First Name _________________
Street _________________________________ Apt. _________
City _______________________ State _______ Zip_________
Telephone: home: (____) ________
alternate: (_____) ________
PLEASE CHECK ALL THAT APPLY. *required to process application.
*1. Print Impaired people qualify for Free Matter for the Blind and Handicapped from the postal service. * Check in front of text if you qualify ___ yes ___ no
*2. What media do you prefer? (Check in front of text) ___
Large Print ___ E-mail ___
___ Braille (should the latter 2 become available)
*If E-mail checked, write your e-mail address: _____________________________________________
3. FLA Membership Selection (Check in front of text) ___ Annual renewal ($10.00 per year) ___
Contributing Member ($50.00 or more per year)
___ Life Member ($200.00 may be paid in up to four installments within one year)
___ Supporting Membership ($250.00 per year group sponsorship)
4. I am interested in helping with (Check in front of text): ___ Public Relations /Education ___ F.L.A.
Board of Trustees
___ Fund Raising
PLEASE CHECK ¬¬¬¬¬_____YES _____NO

A person seeking a nomination for the board must be a member of the Friends of Library Access for at least one year prior to seeking the nomination.