Transcription of NSW Stoma Limited
1 Form ST 02 010216 NSW Stoma LimitedABN 51 610 218 338 Order FormBLOCK LETTERS PLEASEName: _____Residential address: _____Postcode: _____ Telephone: _____ Membership No: _____Appliance item or descriptionSizeQty orderedOrganisation use onlyQty receivedSizeStock codeBrand code _____ Date / / (dd/mm/yyyy) Signature of MemberNSW Stoma Limited recommends that members obtain the advice of an STN or medical practitioner before obtaining or using products, which have not previously been used by the member. Information provided by NSW Stoma Limited about the availability and/or features of any product is not intended to be an advice or recommendation as to the suitability of that product for use.
2 (Please circle applicable)Please accept my freight and order processing payment of $ by: Cash/Cheque/Money order/Credit cardCard type: Only Mastercard or Visa accepted (minimum $ )Cardholder s name (as appearing on card): _____Card number: Expiry: / (mm/yyyy) Cardholder s signature: _____Please send orders to:NSW Stoma Limited , PO Box 164, Camperdown NSW 1450 or email: correspondence to: NSW Stoma Limited PO Box 164, Camperdown NSW 1450 Unit 5, 7-29 Bridge Road, Stanmore NSW 2048 Tel: 1300 678 669 / (02) 9565 4315 Fax: (02) 9565 4317 Email: Web.
