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Membership Application For FOW Canada And/Or Cash Donation

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

Individual:   $30.00    ______     Individual Patron:  $50.00   _______

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.:  ______

Postal Code:       ______________

Phone:        __________________

E-mail address:  _________________________________

Official receipts for tax purposes are issued

Please make cheque or money order payable to:

FOW Canada
301 Benlock Road
Grafton ON K0K 2G0

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