MEMBERSHIP APPLICATION
PRINT & MAIL
Membership in the Phoenix Ostomy Chapter, Inc. provides you with The Phoenix, our chapter newsletter. Please print out the application and mail with your check and a self addressed stamped envelope, for the return of your membership card.
Newsletters are mailed to members and contributors monthly. Inquirers receive 3 complimentary copies, after which we encourgae you to join and become a member or make a donation.
PHOENIX OSTOMY CHAPTER MEMBERSHIP APPLICATION
NAME_____________________________________
ADDRESS__________________________________
CITY_____________STATE__________ZIP_________
PHONE_________________BIRTHDAY______________
I have a____Colostomy____Ileostomy____Urostomy____Continent Ostomy____Other
Reason for surgery_________________________
Date of Surgery____________________________Hospital__________________
Amount enclosed____________
Chapter membership dues--$10.00
Please mail checks payable to:
Phoenix Ostomy Chapter, Inc.
P. O. Box 32185,
Phoenix, Arizona 85064-2185