Diabetes Medicine Bag: Designed to Help Prevent Type 2 Diabetes Among Aboriginal Youth

To order your Diabetes Medicine Bag(s), follow these easy 4 steps:

Step 1:
Enter your contact information and desired number of Diabetes Medicine
Bags. (Choose DMB based on age categories 6 and under, or 7-12.)

Step 2:
Enter a shipping address.

Step 3:
Review your shipping address and order information to ensure it is accurate.

Step 4:
When you’re ready, go ahead and click the “PLACE THIS ORDER”
button.

Once you have placed your order, you’ll see the printable “order
confirmation” page, which displays all your order information, including
your order number. DMB will send you an email invoice confirmation of
your order within 12 hours.

Thank you for choosing to use a Diabetes Medicine Bag (DMB) to
help teach healthy eating and active living. Please fill out the
form below to place your order.

Please send me

* Diabetes Medicine Bag(s) at $299.00 each, plus applicable taxes
and $15.00/bag shipping and handling.

*If interested in 10 or more Diabetes Medicine Bags, contact us at [email protected] or call (toll free) 1.888.532.6898 for a volume discount rate.

Name:

Title/Profession:

Organization:

E-mail Address:

Phone Number:

Address (Line 1):

Street address, P.O. box

Is this address located on an aboriginal reserve?

Yes     

No 

Address (Line 2):

Apartment, suite, unit, building, floor, etc.

City/Community:

Province:

Postal Code

Is your shipping address the same?

Yes     

No 

Address (Line 1):

Street address, P.O. box

Address (Line 2):

Apartment, suite, unit, building, floor, etc.

City/Community:

Province:

Postal Code

If you are an Indian, belong to an Indian Band, tribal council,
or band-empowered entity, and if this purchase is to be
delivered
on to a reserve, your purchase is not subject to the Goods and
Services Tax and/or Retail Sales Tax. If this applies to
you,
please select one of the options below.

Option 1. Individual Indian

As required by Canada Customs and Revenue Agency, please enter
your 9 or 10 digit treaty number here:

Option 2. Indian band or band-empowered entity

Do you represent an Indian band or band-empowered entity?

Yes     

No

As required by Canada Customs and Revenue Agency, please enter
the name of the band and type an “X” on the signature line below.

This is to certify that the band, or band-empowered entity,
is acquiring property on the reserve and/or is acquiring services
for
band management activities. This supply will not be subject to
the Goods and Services Tax and/or Retail Sales Tax.

Band/Entity Name:

Signature of Authorized Officer:

(place an «x» in this box as your signature)

Name

Title of Signing Officer:

Date:

mm / dd / yyyy

Please remit a copy of authorization certificate indicating
that purchases are not subject to the Goods & Services Tax
and/or Revenue Sales Tax, along with your payment. Failure to
do so will result in automatic GST
charges.

Are you a provincial government department whose purchases are
not subject to GST charges?

Yes     

No

If yes, please remit a copy of authorization certificate indicating
that purchases are not subject to the Goods & Services Tax
along with your payment. Failure to do so will result in automatic
GST charges.

When you click the «PLACE THIS ORDER» button below your order
total will be automatically provided and you will be forwarded

to an online reciept page. You will also receive a receipt via
email (if you have specified an e-mail address in Step 1).

Please send your payment and if applicable, a copy of your authorization
certificate to:

ChangeMakers
313 Pacific Avenue
Wpg. MB R3A 0M2

Cheque or money order must be made payable to MACH Diabetes
Prevention Project.

Please note that your order will be shipped after receipt
of payment. Please allow 4-6 weeks delivery time.

The Diabetes Medicine Bag project administrators respect your
right to privacy. All personal information collected will not
be sold, rented, loaned or otherwise disclosed to any third party.
Please view our Privacy Policy
for more information.