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Elder Abuse Brochure & Poster Request Form
Please complete your request for materials below. TO HELP SAVE ON SHIPPING EXPENSES, we kindly ask that you coordinate pick up from our office whenever possible. Address: Vera House, Inc. 723 James St., Syracuse, NY 13206

Please refer to the Vera House website to view samples of each material: http://www.verahouse.org/programs-and-services/evergreen-network

NOTE: Requests for materials outside Onondaga County (or the surrounding area) cannot be accommodated.

Your name *
Your answer
Business/Organization (if applicable)
Your answer
Phone number *
Your answer
E-mail
Your answer
I will pick up my materials on (allow 2 business days for processing):
MM
/
DD
/
YYYY
I am unable to arrange pick up. Please mail to:
Your answer
I would like materials in the following language(s) (if available): *
Brochures requested:
How many brochures would you like? *
Your answer
Wallet cards requested: *
Required
How many wallet cards would you like?
Your answer
Posters requested: *
Required
How many of each poster would you like?
Your answer
Additional info?
Your answer
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