Order Online Test Member's Detail Surname Given Name Address Suburb PostCode Membership Card Number Reference Number Valid Expiration date This order was placed by: Print Name Email —Please choose an option—Geelong Ostomy IncBendigo & District Ostomy Association IncCancer Council of NT IncColostomy Association of NSW IncColostomy Association of SA IncColostomy Association of VIC IncGold Coast Ostomy Association Inclleostomy Association of NSW LTDlleostomy Association of SA Inclleostomy Association ofVIC IncNorth Queensland Ostomy Association IncOstomy Association Of Melbourne IncOstomy Tasmania IncPeninsular Ostomy IncQLD Ostomy Association IncQLD Stoma Association IncToowoomba & South West Ostomy Association IncVictorian Children's Ostomy AssociationWarrnambool & District Ostomy Association IncWide Bay Ostomates Association Inc Member of Distribution Directions: —Please choose an option—JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Month —Please choose an option—20192020202120222023 Year —Please choose an option—Collect from 6 Lewalan Street GrovedalePOST $14 per month supplyPOST Veteran Affairs Delivery Option Please Note : Postage must be paid before order is shipped (See Cash Sales for Payment) Please Note Collection is available only after the 4th of the Month ordered on:Monday, Wednesday, Friday 9.30 am to 2.30 pm Med Cert(if have one) —Please choose an option—Ainscorp (Salts)ConvatecColoplastDansacHollisterOmnigon (Braun, Welland, Eakin)McFarlaneStatinaSutherland Medical Brand Product Code Amount Yes Med Cert(if have one) —Please choose an option—Ainscorp (Salts)ConvatecColoplastDansacHollisterOmnigonMcFarlaneStatinaSutherland Medical Brand Product Code Amount Yes Med Cert(if have one) —Please choose an option—Ainscorp (Salts)ConvatecColoplastDansacHollisterOmnigon (Braun, Welland, Eakin)McFarlaneStatinaSutherland Medical Brand Product Code Amount Yes Med Cert(if have one) —Please choose an option—Ainscorp (Salts)ConvatecColoplastDansacHollisterOmnigon (Braun, Welland, Eakin)McFarlaneStatinaSutherland Medical Brand Product Code Amount Yes Med Cert(if have one) —Please choose an option—Ainscorp (Salts)ConvatecColoplastDansacHollisterOmnigon (Braun, Welland, Eakin)McFarlaneStatinaSutherland Medical Brand Product Code Amount Yes Med Cert(if have one) —Please choose an option—Ainscorp (Salts)ConvatecColoplastDansacHollisterOmnigon (Braun, Welland, Eakin)McFarlaneStatinaSutherland Medical Brand Product Code Amount Yes Med Cert(if have one) —Please choose an option—Ainscorp (Salts)ConvatecColoplastDansacHollisterOmnigon (Braun, Welland, Eakin)McFarlaneStatinaSutherland Medical Brand Product Code Amount Yes Med Cert(if have one) This Order must be submitted BEFORE the 18th of the Month prior to the required month of distribution ( Please note January 13th for February Order) Please be aware of holidays and place your orders early Orders This order form must be submitted BEFORE 2:30pm on the last day we are open BEFORE or on the 20th of the month prior to the required month of distribution (ie. Jan 20th for Feb order). Be aware of holidays and place your orders early. Late placed orders could incur a fee of up to $30 per each company of product you use to cover suppliers special delivery fees Orders will be available for pick-up at 6 Lewalan Street, Grovedale, any Monday, Wednesday or Friday’s after the 5th of the month ordered for between the hours of 9:30am to 2:30pm only. Special Instructions or Messages
