Ostomy Association of Austin Membership Application
Instructions: Print this form, fill it out, enclose your check, and mail it to: Ostomy Association of Austin |
Name_____________________________________________________________________
Type of Ostomy________________________________ Date of Surgery________________
Address: Street_____________________________________________________________
City________________________________________ State _______ Zip ______________
Phone_________________ Email Address _______________________________________
Date of Birth _________________Name of Spouse_________________________________
| Please check one: | I do ( ) I do NOT ( ) |
give permission for my name to be included in the Association newsletter or Membership Directory | |
Signature_________________________________________________ |
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Dues
| Ostomate: | $20.00 | Make checks payable to | ||
| Spouse of Ostomate: | $12.00 | Ostomy Association of Austin | ||
| Professional | $20.00 |
Date application received:________________ Check ( ) Cash ( )
MEMBERSHIP BENEFITS INCLUDE:
Copyright © 2010: Last Modified: 24 January 2010