Order Form

<Select option> Mr Miss Mrs Ms Dr M Mlle Mme Salutation

First Name *

Last Name *

Please provide address in the format: [apt/suite]-[street number] [street name]

Street Address *

City *

<Province> Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Province *

Please do not use spaces or dashes for postal code

Postal Code *

Country

For orders outside of Canada, please call 1-800-BANTING (226-8464) for more information.

<Type of Kit> Type 1 Type 2 At Risk Gestational Professional General/Student/Media Type of Kit *

Please do not use spaces or dashes for phone number(s)

Daytime Phone *

Business Phone

Cell Phone

Email *

Date of Birth

<Unspecified> Female Male Gender

<Type of Diabetes> Type 1 Type 2 Gestational At Risk Impaired Glucose Tolerance Hypoglycemia - Non Diabetes Type of Diabetes Year of Diagnosis

* required fields

YOUR PRIVACY IS IMPORTANT TO US

The information you provide will be used only to fulfil your Diabetes Information Kit request with the Canadian Diabetes Association and provide you with applicable information about programs, services, events and opportunities to support the mission of the Association. We will not use this information for any other purpose without your further consent. To review our privacy policy or to decline consent, please visit: www.diabetes.ca/section_main/privacy.asp.

I do NOT want to have my name and address exchanged with other carefully selected and reputable not-for-profit organizations