Resource Order Form

Agency

Are you interested in? Pamphlets - Limit 50 pamphlets per month. If you need additional quantities, please contact Clearinghouse staff. Posters - Limit one each of up to ten posters.

Fact sheets can be downloaded here.

The materials requested will be used for (check all that apply): * Event Health fair Training/workshop Conference Client/patient/student education Other (please specify)

The number of individuals who will receive the materials is: *

Pick up / Mail: * I will pick up the materials Please mail the materials to me

Additional Comments

Resource Order Form

Limit of 50 pamphlets per month, per person. Limit one each of up to ten posters. If additional quantities are needed, please contact staff at (860) 793 - 9791 or (860) 232 - 4424

Please tell us about yourself: ( denotes required fields)*

Resource Order Form

Limit of 50 pamphlets per month, per person. Limit one each of up to ten posters. If additional quantities are needed, please contact staff at (860) 793 - 9791 or (860) 232 - 4424

Please tell us about yourself: (* denotes required fields)

Please tell us about yourself: ( denotes required fields)*