HOSPITAL AUXILIARIES ASSOCIATION OF ONTARIO
MEMBERSHIP APPLICATION
Benefits and Fees

Proper name of organization:
Hospital Name:
Hospital Address:
Address (line 2):
City / Town:
Postal Code:
Bed Size:
Type (acute, rehab., etc):


President
Name:
Address:
Address (line 2):
City / Town:
Postal Code:
Telephone (212-123-4567):
Fax:
Email:


Secretary
Name:
Address:
Address (line 2):
City / Town:
Postal Code:
Telephone (212-123-4567):
Fax:
Email:


Treasurer
Name:
Address:
Address (line 2):
City / Town:
Postal Code:
Telephone (212-123-4567):
Fax:
Email:


Date organization formed:
Month of Annual Meeting:
Total Members:
Active:
Inactive:
Student Program:
Membership Fee:
Does your organization have representation on your hospital's board:    
Is your organization incorporated:    
Is your organization a registered charity:    




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