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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ORDER FORM back

If you have any problems submitting this form please contact the Web Manager.

A PDF version of this order form can be downloaded here and forwarded to GO by fax or mail.

All orders must be submitted as per the dates on the previous page and before 2.30pm.

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)

       

Membership: If you are not a GO 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 

For Ostomates that are not members of GO your 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: 

If other, please specify here:

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

Supplies Required:

        Company                 Product Code        Amount

1.                        

2.                        

3.                        

4.                        

5.                        

6.                        

7.                        

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.

  by  

  by  

  by  

  by  

  by  

Total Cash Sales  $

Additional Notes: