United Ostomy Association Membership Form

Print out this form with your Web Browser and send it in along with your check, we cannot accept applications on line as payment must be made by check, cash, or money order.   Please register me as a member of the Tallahassee Chapter of the U.O.A. and include me in your mailing list for the newsletter.  Membership includes a subscription to the "Ostomy Quarterly " published by National Headquarters.

Name:________________________________________

Street:________________________________________

City:________________________________________

Zip:________________________________________

Phone:________________________________________

Type of ostomy: colostomy, ileostomy, urostomy, other: ________________

Please enclose a check or money order payable to the U.O.A. Tallahassee Chapter, do not send cash.

Membership $25

U.O.A. Tallahassee Chapter
1215 Hodges Drive
Tallahassee, FL 32303

Last Revised: February 24, 2000