Membership Application

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Triangle Ostomy Association

Name:			Date:
Telephone:			E-Mail:
Mailing Address:
City, State, Zip:
Year of Surgery:		Spouse's Name:
Type of Surgery: (Check all that apply)	[] Colostomy	[] Ileostomy	[] Urostomy (Ileal Conduit)
	[] Other:
[] I am not an ostomate but would like to be a member.
[] I cannot afford the dues but would like to be a member. (Confidential)

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We welcome the membership of ostomates and other persons interested in the United Ostomy Association of America and its activities and appreciate the help they can provide as members. To join, print the form (in landscape mode), complete and send it with a check or money order for $20.00 made payable to Triangle Ostomy Association to:

Mrs. Ruth Rhodes
8703 Cypress Club Dr.
Raleigh, NC 27615

Dues cover membership in both the local chapter and the national organization, including subscriptions to the national Ostomy Quarterly and the local By-Pass.

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