You may use this form to request copies of A&U for your business or organization, or to change the address or quantity for an existing bulk subscription. It is very important that we have the name of an individual contact person along with that individual's phone extention, and email address. We may need to contact you in the future in order to keep our records up to date.

This form is only for bulk subscriptions for organizations, businesses, and institutions. For individual subsciptions please use our standard subscription form.

New Request  Change of address/quantity
First Name:
Last Name:
Organization/Business Name:
Phone:
Fax:
Email:
Shipping Address:
City:
State:	Select a State AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY AE AA AE AP
Zip/Postal code:
How many copies of A&U would you like to receive each month?
	Select an amount 1 10 30 50 80 More than 80
How many clients are served at this location?
	Select a number less than 100 100-500 500-1000 more than 1000
What is the primary function of your business or organization? (please check only one)
	AIDS Service Organization Clinic/Hospital/Doctor's Office Pharmacy Government Agency Retail Store Restaurant/Nightclub Church/Community Center Educational Institution Prison Support Group other
Please give us a brief description of your organization and any comments you have.