Grand Rapids Ostomy Association/UOA Membership Application

Use this form to join the Grand Rapids Ostomy Association. Annual dues are $30.00. We are not set up to take payments on-line; therefore, if you submit this forms electronically, we will bill you . If you prefer, you can print this form and mail it with payment to the address below without using the send data button. Thank You.

All information on this form will be keep confidential

Name:
Street Address:
City: State:
ZIP Code:
Phone Numbers: (Home) (Work)
Email Address:

Colostomy, Ileostomy, Urostomy, Continent Ileostomy, Continent Urostomy, None, Other:

Method of Dues Payment

Please bill me for annual chapter dues of $30.00

Dues payment enclosed, print form and mail with payment. *See below

I would like membership, but cannot pay at this time **See below You may use my name in the chapter Newsletter & Directory: Yes or No

Any help/ information desired, or additional comments:

*If you prefer to print out this form, mail with your check made out to Ninette Dimock
and mail to;
United Ostomy Association, Inc.,
19772 MacArthur, Suite 200
Irvine, CA 92612-2405

** Ostimates who cannot pay dues may become a "local-only" member for a period of one year. During this time, they will receive the local newsletter, but not the national publications such as Ostomy Quarterly

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