Donation Form

The United Ostomy Association of Canada, Inc.

YES I WISH TO DONATE TO UOAC!

(Please type or print all information)

Name ___________________________________________

Address:
Street, Box Number, Rural Route number _____________________________________

Apt. Number _________________________________

Province __________________________________

Telephone _________________________________

City ____________________________

Postal code _____________________

Email __________________________

Amount of donation: (please check)

_____ $100 ____ $75 ___ $50 ____ $25 ____ $10 ____ Other     Amount $ ______

Your donation will be directed to the general operating funds of UOAC, unless it is your wish that it be directed to support a specific program or service.
You may note any special instructions below.

________________________________________________________________________

If you desire, your donation may be in memory of someone.
An acknowledgment of your donation can be sent at your request.

This donation is in memory of: (First and last names) ___________________________

Please send acknowledgment of the donation to:

Name:__________________________________________________________________

Address:
Street, Box Number, Rural Route number______________________________________

Apt. Number ______________________________

Province _________________________________

Telephone ________________________________

City ___________________________

Postal code _____________________

Email __________________________

Please make your cheque payable to UOAC, and send it to:

United Ostomy Association of Canada Inc.
344 Bloor St. West, Suite 501
Toronto, ON M5S 3A7

Thank you for your generosity and support.
If you need more room for responses, please attach a separate sheet.