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 and whether you wish to order the DMB (for children ages 6 and under), the DMB 2 (for children ages 7-12) or both!

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.

To place your DMB order offline:

Contact one of our customer service representatives at 1.888.532.6898 (toll free)
or info@diabetesmedicinebag.com.

Diabetes Medicine Bag Order Form

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.

DMB (for children ages 6 and under)		DMB2 (for children ages 7-12)

Please send me * Diabetes Medicine Bag(s) at $299.00 each, plus applicable taxes and $15.00/bag shipping and handling.		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 info@diabetesmedicinebag.com or call (toll free) 1.888.532.6898 for a volume discount rate.

Step 1. Professional Information

Name:

Title/Profession:

Organization:

E-mail Address:

Phone Number:

Step 2. Shipping Information

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

Step 3. Aboriginal Procedure (if not applicable proceed to Step 4)

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.

Step 4. Government Procedure (if not applicable proceed to step 5)

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.

Step 5. Payment Instructions

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
34 Carlton Street
Wpg. MB R3C 1N9

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.