Arthur Murray Memorial Benefit

APPLICATION FOR REIMBURSEMENT OF TELEVISION/TELEPHONE EXPENSES INCURRED WHILE A PATIENT IN HOSPITAL

Name(Required)

First Last

UA Card #(Required)

Address(Required)

Street Address Address Line 2 City Province Postal Code

Main Contact #(Required)

Secondary Contact #

Email(Required)

Enter Email Confirm Email

Name of Hospital(Required)

Start Date of Stay(Required)

End Date of Stay(Required)

Equipment Rented(Required)

Cost of Equipment Rental(Required)

Reciept(Required)

Max. file size: 50 MB.

Please upload a copy of your rental reciept as proof of purchase