Please fill out the form below,
print the form
and mail to WALWICA with your payment (cash, check, or money order).
Name:
Organization:
Address:
City, State, Zip:
Phone:
Fax:
Email address:
Date needed:
Title
English
Spanish
Subtotal
DVD qty.
VHS qty.
DVD qty.
VHS qty.
Baby Teeth: Love 'em &
Not avail.
$
Leave 'em
Pricing Info: <10 = $10.00 ea; 10-29 = $9.00 ea; >30 = $8.50 ea
Baby Teeth II: The First Dental
Not avail.
Not avail.
Not avail.
$
Visit with Sam Smile
Pricing Info: <10 = $35.00 ea; 10-29 = $32.00 ea; >30 = $30.00 ea
Lift the Lip
$
Pricing Info: <10 = $7.00 ea; 10-29 = $6.00 ea; >30 = $5.00 ea
Grand Total:
$
Mail form to: WALWICA; 13126 NE 138th Place; Kirkland, WA 98034
© 2006, Washington Association of Local WIC Agencies, All Rights Reserved
