app-services — Latinoteca

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Name of Organization*
Type of Organization*
Hospital Health Clinic/ Center/ Provider City/County Health Department Community/Family Center Research Center or University Academic Institution/ School / School District Campaign Independent Community Health Worker/Promotor(a)
Contact Person*
Contact Title
Contact Phone*
Contact Email*
Alternate Contact Name
Alternate Contact Phone
Alternate Contact Email
Organization Address
City
State
Zipcode
Shipping Address:(*)
Book Titles	Adelita and The Veggie Cousins
How many boxes of EACH book title would you like to order (1 box = 250 books)?*
Estimated number of low-income, Hispanic households with children ages 5-9 that you will serve this year*	0-20 21-50 51-100 101-250 251-500 501-1000 1001-3000 3000+
Distribution Plan*
Distribution City
Distribution State
Number of locations to be distributed
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