MEMBERSHIP APPLICATION

THE OTTAWA HEART INSTITUTE ALUMNI INC.
40 Ruskin Street
Ottawa, Ontario K1Y 4W7
Canada

Name:

Address:

City:

Province/State:

Postal/Zip Code:

Country:

Email:

Telephone (H):

xxx xxx-xxxx

Telephone (W):

xxx xxx-xxxx

Language of Correspondence:

English or French (please circle choice)

Remittance:

Membership Fee	$	15.00
I would also like to make a donation now	$
Total	$

Please remit to:

THE OTTAWA HEART INSTITUTE ALUMNI INC.
40 Ruskin Street
Ottawa, Ontario K1Y 4W7
Canada

Signature:

Tax receipts will be issued for all donations. Please note that while donations are tax deductible, the $15.00 membership fee is not tax deductible. Membership fees are the only funds that the Alumni use to cover the costs of operations and administration. All donated funds are used exclusively to purchase equipment and fund other activities that contribute directly to patient care and comfort in the Heart Institute.