Membership Form Step 1 of 5 20% Personal InformationIn this section we will ask for your contact information for the membership application.Name* First Name Last Name Email Address* Enter the email address you would like on your membership record.Phone Number*Enter the phone number you would like used on your membership record.Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Enter the address you would like to use on your membership record. At times we may mail you items of interest. Optional Personal InformationDate of Birth Month Day Year Enter your date of birth.Gender I identify as a female I identify as a male Other Prefer not to answer Ethnicity Asian Black or African American Hispanic or Latino Middle Eastern or North African Multiracial or Multiethnic Native American or Alaska Native Native Hawaiian or other Pacific Islander South Asian White – Anglo-Caucasian I prefer not to answer Other Occupation Medical InformationWhat is your diabetes type? Not diabetic Pre diabetic Gestational Type 1 Type 2 Other What is your current vision status? Sighted Partially Sighted Blind Newsletter PreferencesACBDA Newsletter* Do not Receive the ACBDA Newsletter Receive the ACBDA newsletter via email ACB Braille and E-Forum Newsletter* I would like to receive the Forum newsletter via email I would like to receive the Forum newsletter in large print I would like to receive the Forum newsletter in braille I would like to receive the Forum newsletter on a National Library Service (NLS) Cartridge I do not wish to receive the Forum newsletter Membership DuesPlease select one of the following four options below to determine the amount owed to the affiliate.ACBDA Membership ACBDA full membership (without discounts) - ($10) ACBDA Full Life Time Membership (without discounts) - ($250) ACBDA Membership (with discounts as a life member of ACB or ACBDA) - ($5) ACBDA Membership (with discounts as a life member of both ACB and ACBDA) - ($0) Check OutTotal Membership Dues owed Payment MethodPayPal Checkout MasterCardVisaSupported Credit Cards: MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name Please use PayPal to pay your membership dues. Δ