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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

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