REQUEST FORM

Please print and fax, mail or email to:

Hospice Peterborough
439 Rubidge Street
Peterborough, ON
K9H 4E4
Fax: 742-0064
Email: admin@hospicepeterborough.org

Yes! We would like to invite a speaker from Hospice Peterborough to our meeting:

NAME OF ORGANIZATION: _________________________________________

CONTACT PERSON: ______________________________________________

PHONE: _________________________________________________________

PREFERRED DATE & TIME: ________________________________________

We will contact you promptly to make arrangements!