CORD Membership Form

Print the form, complete it and mail to:

Canadian Organization for Rare Disorders

151 Bloor Street West

Suite 600

Toronto, Ontario M5S 1S4

Date: _________________ ____, 200__



Renewal: ___________ New Membership: ___________ 


Name:_________________________________________ 


Address: _______________________________________ 


City: _____________________________________

Province: ______________________________
Postal Code:_______________

Home Phone: (____) ____________
Work Phone: (____) ____________ 


Email address: ___________________________________



Individual and family membership amount: $25.00

Organization or Corporation membership amount: $50.00

Receipts given for additional donations exceeding $10.00

Registered Charities #89651 3355 RR0001



Please make check payable to:  Canadian Organization for Rare Disorders

Or, please charge (amount) $ __________ to my

Card number: _____________________________
Expiry date: _____/______

Name on card (print): ___________________________________________


Signature: ____________________________________________________