SENIORITY MEMBERSHIP    (Print & Send in)

Name__________________________

Address________________________

_______________________________

City___________________________

State__________________ Zip_____

Telephone # (____)_____________

Date of Birth ___________    oMale    oFemale    oMarried     oWidowed    oSingle

Have you ever been admitted into this hospital before?    oYes    oNo

Please CHARGE my SENIORITY membership to my

o   Visa     o MasterCard

Card # ______________________

Epir. Date ____________________

Signature ____________________


Mail To:

Calais Regional Hospital

24 Hospital Lane

Calais, ME 04619