The National Federation of the Blind
                             1800 Johnson Street
                          Baltimore, Maryland 21230
                        Associate Member Donation Form

     Yes, I want to become an Associate Member of the National Federation of 
the Blind in the classification I've indicated.

____ $10    Associate Member        ____ $25    Contributing Associate
____ $50    Supporting Associate    ____ $100   Sponsoring Associate
____ $500   Sustaining Associate    ____ $1,000 Member of the President's Club
____ I am enclosing $__________ in addition to my membership dues.

I am making payment by the following method:
____  Enclosed personal check    ____ Enclosed money order
____  Credit Card:   ____ VISA   ____ Master Card  or ____ Discover

     Signature: _____________________________________  Date: _________________

     Card Number: ___________________________________  Expires: ______________

(Please Print) Name: _________________________________________________________

Street address: _____________________________________________  Apt. __________

City: ________________________________________________________________________

State: ____________________________________________  Zip: ____________________

(optional) E-Mail address: ___________________________________________________

Phone: (_____) _______________________   FAX: (_____) ________________________

_____  Please have the nearest N.F.B. chapter president contact me.
_____  Please send me information about the P.A.C. (Pre Authorized Check) Plan 
       so I can make monthly contributions automatically.
_____  Please send information about blindness to these people:

1. (Please Print) Name: ______________________________________________________

Street address: _____________________________________________  Apt. __________

City: ________________________________________________________________________

State: ____________________________________________  Zip: ____________________

(optional) E-Mail address: ___________________________________________________

2. (Please Print) Name: ______________________________________________________

Street address: _____________________________________________  Apt. __________

City: ________________________________________________________________________

State: ____________________________________________  Zip: ____________________

(optional) E-Mail address: ___________________________________________________

                 Please send your donations made payable to
                    The National Federation of the Blind
               1800 Johnson Street, Baltimore, Maryland 21230