Gift Card Information Form for Brown County Maternal Mental Health Community Survey

Gift Card Information Form for Brown County Maternal Mental Health Community Survey
Name*

First NameLast Name
Do you live in Brown County, Wisconsin? You must be a Brown County resident to be eligible for gift card. You can check your address using the county’s online map: https://browncounty.maps.arcgis.com/apps/webappviewer/index.html?id=61fba3fd419045e48aa6ba759838387c.*

YesNo
Gift cards will either be sent via mail or picked up at our office (111 N Jefferson St, Green Bay, WI 54301). Please select which delivery method you prefer.*

Please send gift card via mail (address required). Must be Brown County, Wisconsin address. No PO Boxes.I will pick up the gift card from Brown County Public Health (111 N Jefferson St, Mezzanine Level, Green Bay, WI 54301). Our hours are Monday through Thursday 7:30am-5:00pm and Friday 7:30am-11:30am. Please give Public Health 3 weeks from submission before picking up.
Address (if mailing, must be a Brown County, Wisconsin address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Select Your Gift Card Type*

$20 Kwik Trip fuel only gift card$20 Amazon gift card (Alcohol/Tobacco/Lottery/Firearms Prohibited)
Notice: You must click submit to receive gift card.
Gift cards are only available for Brown County, Wisconsin Residents at this time. Thank you!
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Gift cards are only available for Brown County, Wisconsin Residents at this time. Thank you!