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Thank you for supporting the Thyroid Foundation of Canada

Please complete the fillable form - or download a pdf - then print and mail to address at bottom.

Make your cheque payable to Thyroid Foundation of Canada
or fill in your credit card details.

(NOTE: For security reasons, your credit card details must be entered by hand after printing this form.)

An official receipt for income tax purposes will be issued for both membership fees and donations.



Thank you for your support!



Thyroid Foundation of Canada
Membership/Donation Form


ADDRESS
new membership membership renewal donation only
Ms.Mrs.Mr.Dr.
Name

Address


City / Province / Postal code

Telephone

E-mail

MEMBERSHIP

SELECT ONE:

One Year:

Regular /$25 Seniors 65+ /$20 Student /$20 Family /$30

Two Year:

Regular / $40 Seniors 65+ / $30 Student / $30 Family / $50

MEMBERSHIP AMOUNT  
  $ 
(All donations support the work of the
Thyroid Foundation of Canada)
                              DONATION AMOUNT  
  $ 

TOTAL AMOUNT  

  $ 

PAYMENT METHOD         SELECT ONE:         (Enter credit card details after printing)

Cheque    VISA    Mastercard    Card #:

Expiry Date     Month:            Year:            Name on Card:


RECEIPT    Please indicate preference:       by regular mail       to email above

MAIL TO   Thyroid Foundation of Canada, P.O. Box 298, Bath, ON K0H 1G0