Performers at Osaka's Big Stage - Deafblind International

MembershipDeafblind International Individual MembershipI would like to join DbI as an individual memberI would like to renew my DbI individual membershipMember detailsMembership No.Title Surname First nameOrganisationJob TitleAddress (Line 1)Address (Line 2)Town/CityZip/Post CodeState/CountyCountryTelephone no.Fax no.(Please include country and area codes)E-mail address:Are you:a deafblind person a family member a professionalDoes your organisation work primarily for/with:blind people deaf people deafblind peopledisabled people other (please specify)Your contact details will be made available to DbI membersfor DbI purposes but will not be made available forcommercial purposes.DbI Review (please check one box in each category)I would prefer to receive DbI Review on: paper disk*(The disk version of DbI Review is supplied in text only format, on floppy disk)Membership Fee please tick where appropriateI wish to pay for 4 years’ membership at the discountedrate of d100Corporate MembershipThere are three tiers of Corporate Membership:Large corporates Annual fees between d3,000 and d5,000Small corporates Annual fees between d300 and d1,500Mini corporates Annual fees between d100 and d250Mini Corporate membership is available to interestedorganizations from the World Bank list of Heavily IndebtedPoor Countries and Low Income CountriesWe would like to join DbI as a Large / Small / MiniCorporate MemberLibrary membership fees d50 annually(please delete as appropriate)We submit an annual fee of dCorporate members are entitled to receive 25/10/5 copiesrespectively of DbI Review.We would like ______ copiesMember Details:OrganisationRepresentativeAddress (Line 1)Address (Line 2)Town/CityState/CountyZip/Post CodeCountryTel:Fax(please include country & area codes)Email:Website:How to pay?In order to enable us to put your entire membership fee to use, we would kindly ask you to avoid sending us cheques as far aspossible. By arranging your fee via bank transfer, we are able to keep banking charges to a minimum, thereby increasing thevalue of your membership fee. Naturally, for those of you who do not have access to this facility, we will be delighted to acceptyour fee by credit card, cheque or in cash.Payment method Bank Transfer Credit Card ChequeA) Payment by Bank TransferIf paying by bank transfer, please make payment to thefollowing account:Name of Bank: RABOBANKAddress of Bank: Sint-Michielsgestel, The NetherlandsAccount Name: Instituut voor Doven: INZAKE DBIAccount Number: 11.29.09.825Swift Address: RABONL2UIBAN: NL31 RABO 0112 9098 25Date of Bank Transfer:Please quote the Swift Address and IBAN number in yourinstructions for Bank Transfer (If this is impossible and you haveto send a cheque or international postal order thenplease contact us)B) Payment by Credit CardCard type: VISA American Express MastercardCard no:Expiry dateName on card:C) Payment by chequePlease make cheques payable to “Stichting Viataal Zorginzake DbI” and post to: Ton Groot Zwaaftink – DbI Treasurer,Theerestraat 42, 5271 GD, Sint-Michielsgestel, The Netherlands.If paying by Eurocheque, please make out cheque in euros.Please fax this whole page to (08) 9473 5499or return to:The Secretariat, Deafblind International, PO Box 143,Burswood WA 6100, AustraliaJan u a r y – Ju n e 2011 • DbI Review • 75