Please use this form to request materials, provided by the Enhanced Congenital Syphilis Response Project, and subject to availability.

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* 1. Your Name

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* 2. Company

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* 3. Email

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* 4. Phone Number

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* 5. Mailing Address

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* 6. Which materials are you requesting?

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* 7. Do you need a stand to hold these materials?

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* 8. Quantity of Each Poster (if applicable)

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* 9. Quantity of Table Tents (if applicable)

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* 10. Additional Comments or Requests...

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