RFB&D MEMBERS SERVED LIST
To be completed by RFBD Nonmember Affiliates

AGENCY INFORMATION

PLEASE INDICATE THE PRIMARY POPULATION YOUR AGENCY SERVES:

AGENCY NAME:

CONTACT NAME:

SIGNATURE:

PHONE NUMBER:					

FAX NUMBER:

E-MAIL ADDRESS:

STREET ADDRESS:

CITY:						

STATE:

ZIP:

Please list the RFB&D members served by your agency and their RFB&D Membership ID number. RFB&D members may contact RFB&D member services at 800-221-4792 to obtain their Membership ID number if unknown. It is not necessary to list which equipment a particular member will be using. You may make copies of this form to list additional RFB&D members.

This information must be received by RFB&D; failure to do so could hold up the processing of your initial order or affect the ability of your agency to make future equipment purchases from RFB&D. This form is valid for one year from the date of purchase.

RFB&D MEMBER INFORMATION
(Please list the members by name and include their RFB&D Member Identification Number)

1.

2.

3.

4.

5.

6.

7.

8.

9.

Note: You may use a separate sheet of paper for a longer list of names.

RETURN COMPLETED FORM TO:
Recording for the Blind & Dyslexic
Member Services Department
20 Roszel Road, Princeton, NJ 08540
Fax: 609-987-8116       Phone: 800-221-4792

Nonmemlist text.txt			
10/03