Membership/Donation Form

SELECT ONE: new membership membership renewal

LANGUAGE PREFERRED: English French

Name (Mr., Ms., Mrs., Dr.):
Address:
City:
Province/State:
Country:
Postal/ZIP Code:
Telephone:
E-mail:

MEMBERSHIP LEVEL:

One Year:
Select one:
Regular/$25 Seniors 65 +/$20 Student/$20 Family/$30

Two Year:
Select one:
Regular/$40 Seniors 65 +/$30 Student/$30 Family/$50

MEMBERSHIP FEE ENCLOSED:

DONATION: All donations support the work of the Thyroid Foundation of Canada

Please fill in your donation amount only. A total of your membership and donation will be calculated for you on the next screen.

Enter your Donation amount here:
TOTAL DONATION AND MEMBERSHIP:
VISA # and Expiry Date:
Mastercard # and Expiry Date:

If sending by mail please make your cheque payable to Thyroid Foundation of Canada or fill in your Visa details as above and mail or fax to:

Thyroid Foundation of Canada
PO Box 9
Manotick, ON
K4M 1A2