NPWH Mailing List Request Form

NPWH Mailing List Request Form
Guidelines are as follows:
We require PREPAYMENT for all orders. We accept checks or credit card payments (MasterCard,
Visa, Discover, or American Express). Lists will not be sent until payment is received.
The NPWH Mailing list is available for use, if approved, for one-time use only.
The fee is $8,000 for our full mailing list of approximately 30,000 names and addresses.
We will also provide sections of the list at a rate of $0.27 per name (see below for options).
The list is provided electronically (emailed). It can also be provided on CD-ROM or pressure
sensitive labels (additional charges for labels, see below). CD-ROM/labels can be sent via
FedEx if your account number is provided, otherwise it will be sent first-class.
We believe the addresses on our list to be accurate but we cannot guarantee its accuracy or the
outcome of the mailing.
To purchase our list, please fax, email or mail a sample copy of your mailing along with
a signed copy of this contract to NPWH, Attn: Carol Wiley, 505 C Street, NE,
Washington, D.C. 20002; email: [email protected]; Fax: 202-543-9858. Please allow
one week for us to process your request once payment is received.
Requestor Information:
Name: ___________________________________________________________________________
Organization: ______________________________________________________________________
Address: __________________________________________________________________________
City, State, Zip: _____________________________________________________________________
Phone: _____________________________________ Fax: _________________________________
Email: ___________________________________________________________________________
List Delivery Email (if different from above email):
Prepayment by credit card - Check one:
 MasterCard  Visa  Discover  American Express
Credit Card Number: _________________________________________Expires (mm/yyyy):__________
Name on Credit Card (please print):________________________________________________________
Media Type (Check only one):
Sort Order: (Check only one):
 Alpha Order
 Zip Code Order
 Pressure Sensitive Labels (additional charge of $100 if ordering full list on labels, $40 additional fee for all other
orders on labels). FedEx #:
Please indicate your list preference (please check one):
___ Full main list; Approx. 30,000 names
(Cost $8,000)
___ Active Membership; Approx. 2,500 names
(Cost $.27 per name)
Additional preferences for partial list orders if applicable:
___Individual States from  Full main list
 Active Membership
Which States: ______________________________________________________________
I, the undersigned, agree that if my organization’s request to purchase the NPWH mailing list is approved,
it will be used by my organization on a one-time basis only.
Signature _______________________________________ Date______________________
NPWH | 505 C Street, NE | Washington, DC 20002 | (202) 543-9693
Page 1 of 2 (form0815)
*Please fill out this page if purchasing pressure sensitive labels or CD-ROM and
mailing address is different from address on page 1.
Please send labels/CD-ROM to the following address:
Name: _____________________________________________________________
Address: ___________________________________________________________
City, State, Zip: _______________________________________________________
Phone: _____________________________ Fax: ____________________________
Note: All orders will be sent first class unless you provide your FEDEX number on page 1 under
Media Type.
For questions regarding mailing list, please contact:
Carol Wiley
505 C Street, N.E.
Washington, D.C. 20002
[email protected]
Phone: 202-543-9693 ext. 4
Fax: 202-543-9858
NPWH | 505 C Street, NE | Washington, DC 20002 | (202) 543-9693
Page 2 of 2 (form0815)