| Name of contact person: |
Organization: |
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| Address | City |
Province |
Postal Code |
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| Telephone: day (area code) |
Fax: |
Email: |
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| Date of request: |
For office use: |
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| English Manual & Tape: | $20.00 | x [ ] copies = | $ | |
| French Manual & Tape: | $20.00 | x [ ] copies = | $ | |
| English Manual only: | $15.00 | x [ ] copies = | $ | |
| French Manual only: | $15.00 | x [ ] copies = | $ | |
| Tape only (bilingual): | $5.75 | x [ ] copies = | $ | |
| Add postage and handling: | $2.50 | per mailing = | $ | |
| TOTAL DUE: | $ | |||
| PLEASE MAKE CHEQUE OR MONEY ORDER PAYABLE TO THE CITY OF OTTAWA,
and send this form, along with your payment to Attention: Urmila Hivale, Physical Activity Team, Family & Community Health Division 100 Constellation Crescent, 7th Floor East, Ottawa, ON K2G 6J8 | ||||