Order for the month of:  (Please submit separate orders for each month required.  If a holiday issue is required please indicate this in the additional notes at the end of the form)

Choose from January February March April May June July August September October November December         2009 2010 2011

Membership: If you are not a GOA member, we will need to check your Association to ensure that an order has not been claimed for that month and to validate that you have paid your National Access Fee.

I am a member of  Geelong Ostomy ACT & Districts Stoma Assoc Inc Bendigo & District Ostomy Assoc. Inc Cancer Council of the NT Inc Colostomy Assoc of NSW Inc Colostomy Assoc of SA Inc Colostomy Assoc of Vic Inc Gold Coast Ostomy Assoc Inc Ileostomy Assoc of NSW LTD Ileostomy Assoc of SA Inc Ileostomy Assoc of VIC Inc North QLD Ostomy Assoc Inc Ostomy Assoc of Melbourne Inc Ostomy Tasmania Inc Peninsula Ostomy Assoc Inc QLD Ostomy Assoc Inc QLD Stoma Assoc Inc Toowoomba & South West Ostomy Assoc Inc Victorian Children's Ostomy Assoc Warrnambool & District Ostomy Assoc Inc Wide Bay Ostomates Assoc Inc

For Ostomates that are not members of GOA HIC Entitlement Number is

Surname:   Given Name:

Address:    Town:   P/code:

Telephone:    

E-Mail: (Essential for a confirmation of order to be received)

Order Distribution: 

Choose from Collect from 100 Lt Myers St., Geelong Post - Prepaid (Victoria) Post - Prepaid (Not Victoria) Post - Victoria (payment to be sent) Post - Not Victoria (payment to be sent) Other If other, please specify here:

Please Note: Postage must be paid before orders will be posted out.

Supplies Required:

        Company                 Product Code        Amount

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Cash Sales:  If you are collecting your order from 100 Little Myers Street then please do not add cash sale items to your order as you will be able to purchase them on collection of your order.  If you want your order posted and you want to add cash sales to your order you may do so below.  ALL cash sales and orders to be posted, must be paid before your order will be dispatched.

@ $ 8.50    Curved Scissors

@ $ 3.50    Orange Power Air Freshener    please select type Orange Orange and Lime Lemon Myrtle

@ $ 3.00    Floral Air Freshener

@ $12.50    Ozium Aerosol - purse size

@ $ 2.25    Nappy Bags - 100 per box

@ $ 5.50    Mastercloths - Disposable washers - 50 per box

@ $ 6.50    Adept Cloths - Disposable Washers - 70 per box

@ $ 4.50    Rediwipes - Moist Cleansing Wipes - 50 per box

@ $ 6.00    Latex Gloves - 100 per box    Please select size Medium Large

@ $ 1.10    Micropore 1"

@ $ 2.20    Micropore 2"

@ $18.50    Hyperfix Tape

@ $ 3.00    Mattress Protector - Disposable

@ $ 6.00    Mattress Protector - Washable     Please select size Single bed Double bed Queen bed

@ $ 8.50    Night Drainage Stand - Plastic

@ $25.00    Night Drainage Stand - Metal

@ $10.00    Belly Band     Please select size Normal Firm - size 8 - 14 Firm - size 16 - 20 Firm - size 20+

@ $ 8.00    Heat/Wheat Bags     Please select size Square Long

@ $10.00    An A-Peel-ing Recipe Book    

Total Cash Sales  $

Additional Notes: