Arizona Department of Health Services
WIC Local Agency Order Form                                                                                                                                                                                   
           Pg 1
Ship To:                                
(No PO addresses, please)                                  
Agency:   Requested By:  
Street:     Contact Phone:  
   City:     Order Date:  
 State:        Zip:   MM/DD/YYYY  
* All the above fields are required.
For warehouse use only
Order Status
Products ID# # of Items Date Shipped Status
Breastfeeding Items
NEW Breastfeeding Services Poster (English/Spanish-two sided) B-1
NEW Breastfeeding Book, Keep It Simple - English B-2
NEW Breastfeeding Book, Keep It Simple - Spanish B-2S
Cotton Nursing Pads B-55
Breastfeeding Black Cooler Bag B-58
Medela Lactina Plus Breast Pump Electric (Blue Hospital Grade) B-59
Medela Single Use Breast Pump Car Adaptors B-60
Medela Lactina Plus Replacement Case B-79
Medela Lactina Plus Replacement Clip B-80
Medela Dual Hygienikit (For Lactina) B-62
Breastfeeding Scarves B-64
Medela Single Use Breast Pump (Pump in Style) B-65
Breastmilk Storage Bags B-67
Hotline Bag Tag B-68
Hotline Magnets B-69
Hotline Stickers B-70
"Right to Breastfeed" Business Cards NCPS-150

 * All the above SHIP TO fields are required.