![](media/image1.wmf){width="1.2430555555555556in"
height="0.7298611111111111in"}

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  **FOR OFFICE USE ONLY**

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<table>
<colgroup>
<col style="width: 4%" />
<col style="width: 17%" />
<col style="width: 40%" />
<col style="width: 9%" />
<col style="width: 3%" />
<col style="width: 5%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 8%" />
<col style="width: 7%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="10"><p>Department of Health</p>
<p><strong>FORMS AND PUBLICATIONS REQUEST</strong></p>
<p><strong>NOTE: This is your Shipping Label – Use complete street
address (UPS will not deliver to a P.O. Box).</strong></p></td>
</tr>
<tr class="even">
<td colspan="3">Name/Requestor<br />
<strong>     </strong></td>
<td colspan="5">Telephone<br />
<strong>     </strong></td>
<td colspan="2">Date<br />
<strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="5">Name of Organization<br />
<strong>     </strong></td>
<td colspan="5">Internet E-mail Address <strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="10"><p>Shipping Address</p>
<p><strong>     </strong></p></td>
</tr>
<tr class="odd">
<td colspan="3"><p>City</p>
<p><strong>     </strong></p></td>
<td colspan="3"><p>State</p>
<p><strong>     </strong></p></td>
<td colspan="4"><p>Zip</p>
<p><strong>     </strong></p></td>
</tr>
<tr class="even">
<td colspan="10">Does Your Organization have a WIC Program? Yes No</td>
</tr>
<tr class="odd">
<td colspan="10"></td>
</tr>
<tr class="even">
<td>No.</td>
<td><p>Forms or Publication</p>
<p>Number</p></td>
<td colspan="2">Title</td>
<td colspan="3"><p>Quantity</p>
<p>Requested</p></td>
<td colspan="2"><p>Quantity</p>
<p>Shipped</p></td>
<td><p>Back</p>
<p>Order</p></td>
</tr>
<tr class="odd">
<td>1</td>
<td>DOH 961-134</td>
<td colspan="2">The Bold &amp; Beautiful Book of Bean Recipes</td>
<td colspan="3">     </td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td>2</td>
<td>DOH 961-217</td>
<td colspan="2">Poster: Beans- they’re what’s for dinner!</td>
<td colspan="3">     </td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td>3</td>
<td>DOH 961-218</td>
<td colspan="2">Poster: Are you a Bean-ginner?</td>
<td colspan="3">     </td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td>4</td>
<td>DOH 961-219</td>
<td colspan="2">Poster: Sound great?</td>
<td colspan="3">     </td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td>5</td>
<td>DOH 961-220</td>
<td colspan="2">Poster: Are you Well-seasoned?</td>
<td colspan="3">     </td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td>6</td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td>7</td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td>8</td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td>9</td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td>10</td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td>11</td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="2"></td>
<td></td>
</tr>
</tbody>
</table>

**INSTRUCTIONS:** Please put the publications and forms you are
requesting in numerical order by the DOH number. Include both the form
and pub number **and** the title. Order all items in **each** amounts.
Your order will be filled to the nearest packaged amount.

Requestor's name and telephone number **must** be filled in (in case we
have questions about your order.)

**For orders that DO NOT involve a payment:** Send this fully completed
form to Department of Health, PO Box 47845, Olympia, WA 98504-7845.
**Faxed orders are accepted at (360) 664-2929**. Telephone orders are
not accepted. **Do not re-order items that are back ordered.** They will
be sent to you as soon as new stock is available.

**For orders that include payment:** Send this fully completed form and
check to DOH Revenue Section, PO Box 1099, Olympia, WA 98507-1099.

If you have any questions, please contact the DOH Warehouse at (360)
586-9046.

![](media/image1.wmf){width="1.2430555555555556in"
height="0.7298611111111111in"}

  -----------------------------------------------------------------------
  **FOR OFFICE USE ONLY**

  -----------------------------------------------------------------------

<table>
<colgroup>
<col style="width: 4%" />
<col style="width: 17%" />
<col style="width: 40%" />
<col style="width: 9%" />
<col style="width: 3%" />
<col style="width: 5%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 8%" />
<col style="width: 7%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="10"><p>Department of Health</p>
<p><strong>FORMS AND PUBLICATIONS REQUEST</strong></p>
<p><strong>NOTE: This is your Shipping Label – Use complete street
address (UPS will not deliver to a P.O. Box).</strong></p></td>
</tr>
<tr class="even">
<td colspan="3">Name/Requestor<br />
<strong>Susie Smyth</strong></td>
<td colspan="5">Telephone<br />
<strong>360-555-1212</strong></td>
<td colspan="2">Date<br />
<strong>09/30/2002</strong></td>
</tr>
<tr class="odd">
<td colspan="5">Name of Organization<br />
<strong>County Health Department</strong></td>
<td colspan="5">Internet E-mail Address
<strong>Susie.Smyth@chd.org</strong></td>
</tr>
<tr class="even">
<td colspan="10"><p>Shipping Address</p>
<p><strong>1123 Main ST</strong></p></td>
</tr>
<tr class="odd">
<td colspan="3"><p>City</p>
<p><strong>Anytown</strong></p></td>
<td colspan="3"><p>State</p>
<p><strong>WA</strong></p></td>
<td colspan="4"><p>Zip</p>
<p><strong>98000-1234</strong></p></td>
</tr>
<tr class="even">
<td colspan="10">Does Your Organization have a WIC Program? Yes No</td>
</tr>
<tr class="odd">
<td colspan="10"></td>
</tr>
<tr class="even">
<td>No.</td>
<td><p>Forms or Publication</p>
<p>Number</p></td>
<td colspan="2">Title</td>
<td colspan="3"><p>Quantity</p>
<p>Requested</p></td>
<td colspan="2"><p>Quantity</p>
<p>Shipped</p></td>
<td><p>Back</p>
<p>Order</p></td>
</tr>
<tr class="odd">
<td>1</td>
<td>Pub 333-019</td>
<td colspan="2">Rats: Let's Get Rid of Them</td>
<td colspan="3">50</td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td>2</td>
<td>Pub 410-008</td>
<td colspan="2">Protect Yourself From HIV</td>
<td colspan="3">200</td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td>3</td>
<td>Pub 961-160 Spanish</td>
<td colspan="2">Lift the Lip</td>
<td colspan="3">1</td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td>4</td>
<td>CDC</td>
<td colspan="2">Lyme Disease</td>
<td colspan="3">50</td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td>5</td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td>6</td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td>7</td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td>8</td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td>9</td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td>10</td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td>11</td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="2"></td>
<td></td>
</tr>
</tbody>
</table>

**INSTRUCTIONS:** Please put the publications and forms you are
requesting in numerical order by the DOH number. Include both the form
and pub number **and** the title. Order all items in **each** amounts.
Your order will be filled to the nearest packaged amount.

Requestor's name and telephone number **must** be filled in (in case we
have questions about your order.)

**For orders that DO NOT involve a payment:** Send this fully completed
form to Department of Health, PO Box 47845, Olympia, WA 98504-7845.
**Faxed orders are accepted at (360) 664-2929**. Telephone orders are
not accepted. **Do not re-order items that are back ordered.** They will
be sent to you as soon as new stock is available.

**For orders that include payment:** Send this fully completed form and
check to DOH Revenue Section, PO Box 1099, Olympia, WA 98507-1099.

If you have any questions, please contact the DOH Warehouse at (360)
586-9046.