AVI MEMBERSHIP APPLICATION

By /
Last Name ____________________________________  First Name   ____________________________
Home Address  _________________________________________   Home Phone  __________________
City/State/Zip    _________________________________________  Country   _____________________
Business Name & Address (If Professional Membership)   ______________________________________
City/State/Zip    _________________________________________  Bus. Phone   ___________________
Fax Number  __________________________________  e-mail address  __________________________

Type of Membership:         New       Renew
The membership year runs from January 1 through December 31

Cert. AVT Annual Fee ($35) Professional   ($40) Method of Payment:
Individual/Family – U.S.  ($30) Donor   ($100)
Check enclosed Money order
Individual/Family – Canada/Mexico  ($33.50) Patron   ($200)
VISA MasterCard
International (Other Countries)  ($39) Lifetime – Individual/Family  ($400) Card Number:  _____________________________
Full-Time Post Secondary Student  ($20)* Century Club-Corporate  ($1500) Expiration Date:  __________________________
* Membership must be accompanied by a letter from advisory on University Stationery Donation Only  $_____________ Name on Card:  ____________________________
Signature:  _______________________________
If this is a gift membership, name and address of donor:  __________________________________________________________________________

In Honor of   ________________________________ In Memory of   ______________________________
Address  _______________________________________ City/State/Zip  __________________________________

All contributions tax deductible.   Payments must be in U.S. currency.

Other information (For AVI use only.  Check all that apply)

Adult who is Hearing Impaired College/University Student Physician
Audiologist Grandparent Speech-Language Pathologist
Auditory-Verbal Therapist Parent of a Child who is Hearing Impaired Teacher of the Hearing Impaired
Other (describe)   _________________________________________________________________________________________
Child’s Parent or grandparent, please complete:
Name   ____________________________________________________   D.O.B.   _______________________________

Child’s Therapist Name   _____________________________________________   AVI member       Yes    No
Address  ________________________________    City/State/Zip  ________________________  Phone  _____________

I know that AVI counts on its volunteers to help make a difference in our children’s lives.  Please contact me, I’d like to help.
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