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Membership
Application
United
Ostomy Support Group, Ottawa, Inc.
The
following information is kept strictly confidential. Membership is open to Ostomates,
family members, medical and health care professionals, Ostomy Equipment suppliers and
any other interested persons.
NAME:______________________________________
TELEPHONE:_______________________________
ADDRESS:______________________________________________________________________________
EMAIL
ADDRESS:_________________________________________________________________________
Would
you prefer to receive the newsletter by
Email? O
Yes O No
O FULL MEMBERSHIP $35.00 Includes one
year's membership in the Ottawa Support Group, monthly newsletter,
membership in UOA Canada Inc. and Issues of Ostomy Canada
Magazine.
O ASSOCIATE MEMBERSHIP $20.00 Includes one year's
membership in the Ottawa Support Group, a
monthly newsletter.
CHECK ALL THAT APPLY:
O
new member O renewing member O
colostomy O urinary
O continent
diversion urostomy
O
ileoanal pouch O ileostomy
O continent ileostomy O MD, ET, Supplier,
Spouse
O
Male O Female
O I am unable to pay at this time, but would like to be a member.
How
did you learn about UOSG?__________________________________________________________
ENCLOSED:
Yearly Membership Dues: $___________ Donations $
__________Total $____________
Make Cheque payable and mail to:
United Ostomy Support Group, Ottawa Inc.
P. O. Box 11134, Station H,
Nepean, ON K2H 7T8
TAX
RECEIPTS WILL BE ISSUED FOR DUES AND DONATIONS. OSTOMY
CANADA MAGAZINE
IS PRODUCED TWICE A YEAR, IN SPRING AND AUTUMN
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