Form Mc 370 - Order Form

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State of California-Health and Human Services Agency
Department of Health Care Services
Shipping Information
Order Form
Pub 406A
Maximum order quantity 300 per language.
Language
Qty
Language
Qty
All orders are sent Standard Delivery
 English
 Spanish
Special Delivery is available for an additional cost
 Arabic
 Hmong
Special Delivery requested:
UPS
FedEx
Your billing Authorization/Account number (required)
 Armenian
 Korean
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Overnight
2-Day
(allow 3-4 days)
(allow 4-6 days)
 Cambodian
 Russian
To process your order choose one of the following:
 Chinese
 Tagalog
FAX: (916) 364-6612 OR EMAIL:
 Farsi
 Vietnamese
Applications
Handbooks
Maximum order quantity 300 per language.
Maximum order quantity 300 per language.
Language
Qty
Language
Qty
Language
Qty
Language
Qty
 English
 Spanish
 English
 Spanish
 Arabic
 Hmong
 Armenian
 Korean
 Armenian
 Korean
 Cambodian
 Russian
 Cambodian
 Russian
 Chinese
 Vietnamese
 Chinese
 Tagalog
 Farsi
 Farsi
 Vietnamese
 Hmong
PUB 406A (Errata to the joint application) is automatically included if necessary. You may order additional inserts if needed.
All information is required to process your order.
Organization
Category
Mailing Information
    Residence
  Business
Please indicate the
Organization Name:
category your
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Organization represents.
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Organization/Person
Delivery Address:
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ordering the material:
(No P.O. Boxes)
Check the appropriate box
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(required)
City:
Zip Code:
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 EE
 CA A
Contact Person Name:
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Number (required)
Phone:
Fax:
(
)
(
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-
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-
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Email Address:
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Shipping Date
Order ID
For Internal
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Use Only
Shipping ID
MC 370 (Rev 06/13)

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