Free VIDEO ORDER - Indiana

VIDEO ORDER

State Form 36897 (R5/04-05) Indiana State Department of Health

INSTRUCTIONS: 1. Complete and return to: INDIANA STATE DEPT. OF HEALTH Office of Public Affairs 2 N. Meridian Street Indianapolis, IN 46204-3003 317.233.7257 FAX: 317.233.737

Date:
(Month, Day, Year)

Name:
(City)

Organization:
(State) (ZIP Code)

Address: E-mail Address: __________________________
(Area Code)

(Street)

Daytime Telephone Number:

Please order one video per line Title Number Date(s) of Use
(First Semester)

Video Title

Date(s) of Use
(Second Semester)

Alternate Dates
(At least two weeks from first-choice date)