Unite for Bleeding Disorders Magnets Request Form

Thank you for requesting more magnets for your Hemophilia Treatment Center! We appreciate your support in spreading the word about Unite for Bleeding Disorders! Please answer the questions below to provide us with the information we need to send you more magnets.

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* 1. What is your preferred # of magnets to receive? (quantities will be sent while supplies last)

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* 2. Which Hemophilia Treatment Center are these magnets for?

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* 3. Which Unite Walk Chapter is your HTC affiliated with?

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* 4. What mailing address should we ship the magnets to?

Name *

Company *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Department

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* 5. Who should we contact, if needed, regarding your request?

Name

Email Address

Phone Number