Applicant: ___________________________________________________
Address:_____________________________________________________
City/State/Zip:_________________________________________________
Phone (Home):________________________ Phone (Work):_________________________
This application is for the following memberships:
|
p |
Family Membership: For survivors of brain injuries, family members, their family or extended family. Enter all names and check appropriate boxes below. Yearly dues are $35.00 (one address); $10.00 for each additional address. |
|
p |
Professional Membership: For professionals or health care providers in a field related to brain injury. Please specify professional field below. Yearly dues are $50.00. |
|
p |
Corporate Membership: For companies wishing to further the goals of NVBIA. This membership entitles the joining corporation to two mailings, if requested. Corporate Members are also identified in Heads Up!, the NVBIA newsletter and receive a 1/4 page ad. Please indicate company product or service below. Yearly dues are $200.00. |
|
p |
Courtesy Membership: For survivors of brain injuries, family members, their family, or extended family, who are unable to afford a basic membership. Enter all names and check appropriate boxes below. Yearly dues are $10.00. |
Name of Survivor:________________________________________________________
Professional Field:________________________________________________________
Corporate Info:__________________________________________________________
Remarks:_______________________________________________________________
________________________________________________________________
Please
print this form, complete, and mail it to
NVBIA, P.O. Box 2148, Springfield, VA 22152
Checks should be made out to NVBIA
Donations
made to NVBIA are fully tax deductible as allowed by law.
NVBIA is a 501(C)3 tax exempt organization (Tax
ID Nr 54-1240683).