GEELONG OSTOMY  Inc

100 little Myers Street Geelong Victoria Australia 3219

Ph: 03 5222 3168  Fax: 03 5223 2659  e-mail: goainc@ncable.net.au

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MEMBERSHIP APPLICATION  back

If you wish to apply for membership with GOA, please complete the form below and submit.  Payment and copies of Medicare and or Concessional cards must be forwarded to 100 Lt Myers Street, Geelong  Vic 3220.

Alternatively you can download the form in PDF format here, and forward the form to GO.

MEMBERSHIP APPLICATION INFORMATION

GOA Membership:

Concessional membership is only available to holders of a current Pension Concession Card or a current Health Care Card.  Veteran Affairs Gold Card holders will have their membership paid by veteran Affairs: Please type your concession/ gold card number below.

Concessional Card/Veteran Affairs Gold Card:

Please note: all membership renewals are due on 1st July every year.

PERSONAL INFORMATION

Title:             Date of Birth:

Given Name:      Surname:

Medicare No:

Home Address

Street/P.O. Box: Line 1

Street/P.O. Box: Line 2

Town:   State:   Post Code:

Postal Address (if different from the above home address)

Street/P.O. Box: Line 1

Street/P.O. Box: Line 2

Town:   State:   Post Code:

Contact Details

Home Phone:       Mobile Phone:

Email:

Emergency Contact Person:

Emergency Contact Phone:

STOMA INFORMATION

Stoma type:    Stoma Status:

Stomal Therapy Nurse:

Hospital:

ADDITIONAL INFORMATION

Comments or special requirements