Membership Form

 

 

 

 

 

Benbulben Chronic Obstructive Pulmonary Disease Support Group

 

Expression of Interest Form

 

Please return this form if you would like to be contacted regarding the next support group meeting.

Name______________________________________________

 

Address____________________________________________

                ___________________________________________________

Telephone_________________________

Signed___________________________________________________

                                                                                      (Please tick)

 

   I am interested in becoming a committee member      Yes  –        No   –

 

“Alone we can do so little : Together we can make a difference.”

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