a Turbo Group product
Name:________________________________________________________________
Full Mailing Address:
Street(1):_____________________________________________________________
Street(2):_____________________________________________________________
City:__________________________________State:_____Zip:__________________
Telephone:___________________________________
Social Security Number:________________________
Signature: ___________________________________
Enclosed is $___________ for registration of my living will/health care proxy for the state(s) of: _________.
Documents to be registered:
_____ Living Will, _____ Health care proxy/health care power of attorney, _____ Organ donor information.
Total number of pages: ______
____________________________________________________________________________________
Registry membership is for two years with two year renewals. Costs: $ 39.95 for up to 4 pages, $ 5.00 for each additional page, $ 24.95 for renewals and/or changes of original membership documents.
The North American Registry of Living Wills™ is a service which allows immediate access to advance medical directives for its members in good standing. The Registry reserves the right to revoke the membership of anyone who abuses its services.
©1996, 1997 The Turbo Group, Inc.