Immunization Program Public Education Materials Order Form
Department of Health
PUBLICATION REQUEST FORM
The New York State Department of Health offers limited quantities of free educational materials to New York State residents and organizations.
? No more than 10 different publications may be ordered.
? You may order up to 200 copies of each (10 copies of posters) or provide details on why more are needed.
? For fastest delivery, please list items in numerical order by code number. These orders will be processed first.
? Bulk orders cannot be delivered to post office box numbers.
Complete and email this form to OGS.SM.GDC@OGS.
PUBLICATION TITLE 1.
PUBLICATION NUMBER
LANGUAGE
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10.
QUANTITY
NAME ORGANIZATION (IF APPLICABLE) STREET ADDRESS CITY, STATE, ZIP CODE PHONE NUMBER
MAILING INFORMATION
DATE
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