Text Box: BENDIGO and DISTRICT OSTOMY ASSOCIATION INCORPORATED A.0018335K APPLICATION FOR MEMBERSHIP All correspondence including orders to be sent to the SECRETARY, BENDIGO OSTOMY ASSOCIATION P.O. BOX 404 GOLDEN SQUARE VICTORIA 3555 This application form to be completed fully and returned with annual membership fee of $50 plus postage if applicable (DVA MEMBERS EXEMPT) VICTORIA $9 ALL OTHER $10 A photocopy of your medicare card to be included with this application Text Box: TITLE (please cicrcle one) MR MRS MS MISS Text Box: (block letters please) SURNAME..................................................................... GIVEN NAMES.......................................................................................... POSTAL ADDRESS................................................................................... TOWN/CITY.......................................................POSTCODE................... DATE OF BIRTH / / DATE OF OPERATION / / TELEPHONE NUMBER (HOME)........................................................... (WORK/MOBILE)........................................... MEDICARE NO...................................DVA NO....................................... SIGNED ................................................................. Text Box: OPERATION DETAILS: HOSPITAL ................................................................................................... ADDRESS:................................................................................................................................................ STOMAL THERAPIST:........................................................................................................................... CONTACT PHONE NO....................................................................................AH. ............................. SURGEON....................................................................... GP................................................................... Text Box: ENTITLEMENT NUMBER (Office use only) Text Box: PRODUCT Text Box: PERMANENT STOMA Text Box: TEMPORARY STOMA Text Box: COLOSTOMY Text Box: ILEOSTOMY Text Box: UROSTOMY Text Box: FISTULA Text Box: DRAIN Text Box: OTHER Text Box: PLEASE LIST, TYPE, BRAND AND SIZE OF APPLIANCES REQUIRED AND SUNDRY PRODUCTS TAPE ETC.