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Membership Application

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Membership
Membership Application

- Step 1 of 4

Personal Information

First Name: *

Middle Name:

Last Name: *

Suffix:

Date of Birth: *

Gender: *

Male
Female
Other

Address

Address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

County / Parish:

Contact Information

Email Address:

Choose Phone Number Type(s): *

Home
Mobile
Work

Home Phone Number: *

Enter only numbers (no dashes or spaces)

Mobile Phone Number: *

Enter only numbers (no dashes or spaces)

Work Phone Number: *

Enter only numbers (no dashes or spaces)

Membership

Please select one of the following membership types: *

Life Member (Legally Blind) - $50.00
Life Member (Low Vision) - $50.00

Please select one of the following BVA Bulletin formats: *

Online Version
Email PDF Version
Email Word Version
Mail Print Version
Mail CD

Military Service

Branch of Service:

Wartime Period:

World War II (December 7, 1941, to December 31, 1946)
Korean Conflict (June 27, 1950, to January 31, 1955)
Vietnam War (February 28, 1961, to May 7, 1975)
Gulf War (August 2, 1990, through a future date to be set by law)
Peacetime

Recruited By:

NOTE: Submit a letter from certifying official affirming legal blindness or low vision status.

Click or drag files to this area to upload. You can upload up to 5 files.

You may request assistance in obtaining the letter from a VA VIST Coordinator by utilizing VA Form 10-5345 Request for and Authorization to Release Health Information to a non-VA (or third-party) individual or organization. You may also contact us via email: membership@bva.org, or via telephone: (800) 669-7079 x 330 for assistance.

Billing Information:

Choose one of the following membership payment methods: *

$50.00 Debit or Credit Card Online Payment
$50.00 Check or Money Order - Mail to: BVA, PO Box 90770, Washington, DC 20090
Please Call Me

Additional Notes

Blinded Veterans Association
BVA is a 501(c)(3) tax-exempt, non-profit organization

CONTACT US
Blinded Veterans Association
PO Box 90770
Washington, DC 20090
Phone: (800) 669-7079
Email: bva@bva.org

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