Return application and
payment to:
WISCONSIN BRAILLE Inc.
Membership Chair
557 Milky Way
Name
____________________________________________________________
Address
__________________________________________________________
Phone ______________ Fax ______________ E-Mail
______________________
In what format would you like the newsletter and
other correspondence sent to you?
(check one)
Print __
Braille ___ E-mail ____
What is your affiliation with the braille-reading community (Check all that apply)
VI Teacher ____
Braille Transcriber ____
Parent _____ Proofreader ____
Administrator
____
Educational Assistant ____
Producer ____ User
____
O&M Provider ____ Other ____
Membership Opportunities:
____ Regular
Membership (Annual Membership = $10.00)
____ Sustaining Membership (Annual Membership +
Contribution = $30.00)
____ Lifetime Membership (One-time Contribution = $200.00)
Note: All contributions over and above the annual
regular membership are tax-deductible.
Total Amount Enclosed _____________