MEMBERSHIP APPLICATION FOR FOW CANADA AND/OR CASH DONATION

Yes, I would like to improve the life-style of needy ostomates by applying for the following membership and/or giving the following cash donation.


Individual:   $25.00    ______     Individual Patron:  $45.00   _______
 
Corporate: $100.00   ______     Corporate Patron: $250.00 _______

Chapter, Group or Association: $1.00 per member (maximum of 150.00)  _______

Please accept my donation of: $ ____________

Name:     _________________________

Street:     _________________________   City:  _________________  Prov.:  ______

P.C.:       ______________    E-mail address:  _________________________________

Please make cheque or money order payable to:

FOW Canada
c/o 19 Stonehedge Park
Ottawa, ON   K2H 8Z3