Illinois Women Win with Health Care Reform MATERIAL ORDER FORM * required ORGANIZATION/ AGENCY NAME: AGENCY CONTACT * TITLE: ADDRESS: * CITY: * STATE: * ZIP CODE: * PHONE: * (in 000-000-0000 format) EMAIL: Please provide a brief description of your target population if you are able to (e.g. % living below poverty, racial/ethnic breakdown, age range, etc.): We are offering free Illinois Women Win with Health Care Reform pocket guides. The English version is currently available and Spanish version will soon be available. Please indicate the quantity that you would like to order in the form below (limit 200): English Pocket Guides Qty Spanish Pocket Guides Qty SHIPPING: If you are an IMCHC member, shipping is free! If you are not a member, there is a $5.00 shipping fee for each order. A check can be payable to and mailed to: IMCHC 1256 W. Chicago Ave., Chicago, IL 60642 To find out if you are a member, please contact Kathy Waligora. To become a member today, please click here. To learn about the benefits of becoming a member click here. Thank you for your order and support. Please contact Kathy Chan with any questions or for promotion ideas.
* required
ORGANIZATION/ AGENCY NAME:
AGENCY CONTACT *
TITLE:
ADDRESS: *
CITY: *
STATE: *
ZIP CODE: *
PHONE: * (in 000-000-0000 format)
EMAIL:
Please provide a brief description of your target population if you are able to (e.g. % living below poverty, racial/ethnic breakdown, age range, etc.): We are offering free Illinois Women Win with Health Care Reform pocket guides. The English version is currently available and Spanish version will soon be available. Please indicate the quantity that you would like to order in the form below (limit 200):
English
Pocket Guides Qty
Spanish
If you are an IMCHC member, shipping is free!
If you are not a member, there is a $5.00 shipping fee for each order. A check can be payable to and mailed to: IMCHC 1256 W. Chicago Ave., Chicago, IL 60642
To find out if you are a member, please contact Kathy Waligora.
To become a member today, please click here. To learn about the benefits of becoming a member click here.
Thank you for your order and support. Please contact Kathy Chan with any questions or for promotion ideas.