Delaware Health Statistics Center
Emailing List

Title: ______________

Name: ______________________________	     ______________________	_________	
		Last                                First                   MI

Position Title: ______________________________________________________________

Company/Organization: _______________________________________________________

Address: ___________________________________________      _______	  _________
			City                               State           Zipcode 

Email Address: ______________________________________________________________

Telephone: ___________

Date Request Submitted:  _______________


Mail this form to:
Delaware Health Statistics Center
Division of Public Health
Delaware Health and Social Services
417 Federal Street
Jesse Cooper Building
Dover, DE 19901
Tel No. 302.744.4541
Fax No. 302.739.4784

DHSC Emailing List Sign-up Form
Doc #35-05-20/09/05/06