Annual Membership dues are $25.00 which includes receiving
the national magazine, The Ostomy Quarterly and our monthly
newsletter, the Broward Beacon. Please make checks payable to BOA,
print and fill out this Membership Application Form and mail to:
Mr. Julius Mann, 2404 Antiqua Circle, Apt B2, Coconut Creek, FL 33066-1011

Name _________________________ Age ____ Year of Surgery________

Street _________________________ Apt. ____ Type of Ostomy________

City _________________________ Zip _______ Phone (___) _________

e-mail address: _________________________

__ I am an ostomate. I would like to become a dues paying member.

__ I am also enclosing a contribution.

__ I am an ostomate and would like to become a member but cannot afford      dues at this time.   (This information is kept in the strictest confidence.)

__ I would like to become an Associate Member (non-ostomate).