Publication Request Form

Publication Request Form

Complete this form to let the Allegany County Department of Health know that you need more education materials at your location. You can also call us at 585-268-9437.
Date

MonthDayYear
Date
Is this request for a...
Select Location:
Please select your trail location.
Select Topic:
Please let us know if the trail location needs more pamphlets of tick removal kits.
Who is requesting the material?

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
What is your agency or community based organization?
(ex: Allegany County Department of Health, Ball Club, Girl Scouts, Store, Library)
Mailing information to have the publications delivered directly to you. Bulk orders cannot be delivered to post office box numbers

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please visit https://www.health.ny.gov/publications/4208/ for a list of available publications from the NYSDOH.

Please visit https://www.health.ny.gov/environmental/publications.htm for a list of available Environmental Health Publications from NYSDOH.
What Materials Are You Requesting? Please click "add row" for more than 3 publications. Maximum of 10 publications. Quantity maximum of 200.
Please verify that you are human
Should be Empty: