Health Groups in Washington
List Rental Order Form
Please complete the following form to order the
Health Groups in Washington
mailing list. Required fields are indicated in
GREEN
. If you prefer to download and print a PDF version of this form, please
click here
.
Delivery Method:
CHOOSE!
MS Excel -- Via E-mail
Tab-Delimited Text File -- Via E-mail
Laser Labels -- Via U.S. Mail
Your Information
Name:
Title:
Organization:
Street Address:
City State Zip:
-
Daytime Phone:
-
-
E-Mail:
Not Exempt
Exempt
Click indicate here if located in DC, but with tax-exempt status. (Please provide documentation.)
Payment Summary
Sub Total:
$
Shipping/Handling:
$
DC Sales Tax:
$
GRAND TOTAL:
$
Check your information carefully before submitting your order.