CANSURVIVE RESEARCH ASSN Inc.
P.O.Box 238. Nambour Qld. 4560.
Centre Address: 69 Park Rd, Nambour Qld. 4560
Phone 07:5441 5730  email: info@ucansurvive.org
 
MEMBERSHIP FORM
 

We welcome members who are not only cancer patients but members of the caring community who believe in the principles of CANSURVIVE. Helping to bring a better service for those in need in the future.

NAME........................................................................................................................

Mrs Mr Ms Miss Dr.

ADDRESS................................................................................................................

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............................................................................... PC ...........................................

PHONE: ..............................…....... .FAX: ...................................

Email:.................................………………….................................
 
As from July 2009 the membership fee will be as follows.
Membership:1 year $45          2 years: $80 .
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I wish to make a donation $ ...................... All donations are tax deductible.

DO YOU HAVE CANCER? .....................................................................................

If yes, please give brief details.

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Signed:.............................................................................................

Date:.............................................................................

Please print and send or email this signed form back to CANSURVIVE.

With your payment: Cheque, Money order or Credit Card:

Bankcard Visa Mastercard

Card No:: ………/…..…../…..…../……..…

 

Expiry date: ………./………...

CANSURVIVE RESEARCH ASSOCIATION Inc.

Offering information and support for those challenged by cancer.     - Supporting You -

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