Pennsylvania Council of the Blind Application for Returning Convention Student Stipend

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                                                                                          Date: 
Full Name: * 
First Last
Mailing Address: * Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip CodeCountry
E-mail Address: * 
Home Phone: * - 
Area Code Phone Number
Mobile Phone: - 
Area Code Phone Number
Please answer the following questions:
1. How many times have you attended the PCB convention? * 
2. Have you become involved in organizing the student affiliate? * Yes
No
3. Have you joined PCB as a member at large or at a local chapter affiliate? * Yes
No
4. In 100 words or less, please tell us why you would like the support of the $100.00 stipend.  *