Mailing Label Request Form

If you prefer to send your own mailing rather than advertise in one our our publications, you can purchase a one-time only mailing list. Mailing lists can be purchased for $.10 per name, plus a $25.00 processing fee.

Name *

Title

Phone

Email *

Street Address *

Street Address 2

City *

State * AL AK AR AZ CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip Code *

Purpose of Mailing List Purchase *

Ohio Counties Requested (please list counties or write ALL for the entire list) *

By selecting "I agree" below, you agree to the following: I agree that the purchase of this mailing list is for a one-time use only. I understand that the addresses may NOT be entered into a database or copied for future use and that I do not have the right to distribute, disclose, duplicate, reproduce or retain any information contained on the labels. I agree to be liable to the Ohio Chapter, American Academy of Pediatrics in the amount of $500.00 for breach of this agreement; said amount will be paid to the Ohio AAP each time this contract is breached. *

I agree

I do not agree