.................................................................................................................................................
Hearing Loss Association of Albuquerque - Membership Application, Renewal, Subscription, Donor Form



Name  ______________________________________________________________________________________________


Address  ___________________________________________________________Apt. Number ______________________


City  __________________________________________________________  State_______Zip ______________________


Phone (Voice) ____________________ TTY _________________  email ________________________________________
          Please check this box if you use a CapTel phone

                                                               New  Renewal
PLEASE CHECK APPROPRIATE LINE     ____    ____    Annual Chapter Fee: $15.00

  ____    ____     Newsletter Subscription Only:  $7.50

  ____    ____      Donation:  $ ________________


                         Please make check payable and mail to: HLAAbq  l  P.O. Box 36792 l Albuquerque, NM 87176
We invite you to
Join the
Hearing Loss Association of Albuquerque

You can join the Albuquerque chapter by printing and filling out the application blank below and mailing it to our treasurer along with your check or money order to cover the annual chapter fee.  The annual chapter fee also includes your subscription to the chapter's newsletter - Wired for Sound.

If you would like to learn more about or join the national HLAA organization,
you can do so at the national web site:
www.hearingloss.org
Return to home page