Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 3Prefix *Mr.Mrs.Ms.MissDr.Name *FirstMiddleLastSuffixGender *MaleFemaleOtherPrefer not to sayBirthdate *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Phone Type *MobileHomePhone Number **Note: Do not add country code to phone number.Email *EmailConfirm EmailAddress *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCounty / ParishAre you legally blind or low vision? *Legally BlindLow VisionNextBranch of Service *ArmyNavyMarine CorpsCoast GuardAir ForceSpace ForcePeriod of Service *World War IIKorean ConflictVietnam EraPersian Gulf WarOEF / OIF / ONDOtherRace / Ethnicity *AsianWhiteHispanic / Latino DescentBlack or African AmericanAmerican Indian or Alaska NativeNative Hawaiian or other Pacific IslanderOtherPrefer not to sayPreviousNextAttestation *I, the undersigned, having read, understood, and confirmed that I meet all the eligibility criteria outlined in the Blinded Veterans Association's Bylaws Article 3, Section 1, which states, "Any person having honorably served or currently serving in the armed forces of the United States, qualifying for Department of Veterans Affairs (VA) Blind Rehabilitation Service (BRS), is eligible for membership," do hereby acknowledge that all the information submitted in connection with my application for membership is true and correct to the best of my knowledge. I understand that providing falsified information on this application is grounds for the denial of membership to the Blinded Veterans Association and may disqualify me from future membership. *Waiver *I, the undersigned, hereby attest that I give Blinded Veterans Association (BVA) permission to use any images, audio, video, or other media captured of me during official BVA activities for promotional, marketing, fundraising, and other activities. I understand that BVA may use this media in a variety of ways, including on its website, social media, and in print materials. I also understand that I may not be able to review or approve BVA's use of this media in advance. I agree to this attestation statement freely and voluntarily. I understand that I may withdraw my permission to use my media at any time by contacting BVA in writing. By joining BVA, you agree to receive promotional and marketing materials. *Recruited ByRegional Group Affiliation*Note: If unknown, leave blank.PreviousSubmit
