Visually Impaired Veterans of America

South Carolina Lowcountry Chapter

South Carolina Low Country Chapter | Mission, Goals & Vision
Schedule of Events | Links | Application Form

Membership Application

I am enclosing $15.00 for my VIVA dues ____.
NAME: ______________________________________
ADDRESS: ___________________________________
CITY: _______________ STATE: ____ ZIP: _________
PHONE: (Area Code) ______ NUMBER: ___________
E-mail address: _____________________________

Are you:
      Legally Blind ____    Visually Impaired ____
      Deaf-blind ____        Sighted ____

I would like the VIVA newsletter and the Braille Forum in:
      Braille ____    Large Print ____    Disk ____
      email ____      regular print ____

I do not want these publications ____

I am including a tax deductible donation to VIVA in the amount of: $_____.___

Send this form and enclosed check to:
Charlotte Noddin, Treasurer
63204 Crown Point Road
Coos Bay OR 97420-9637

Send change of address information to:
Barbara Alexander, Secretary
5321 Plaza Lane
Wichita KS 67208-4150

Note: South Carolina Residents: Contact Max Hearn at (843) 821-0251

South Carolina Low Country Chapter | Mission, Goals & Vision
Schedule of Events | Links | Application Form