OUT Maine · $ Appeal - Provider Kit

Contact Information

Name

*

Prefix

First Name

Last Name

Suffix

Job Title

*

Email

*

Verify Email

*

Email type

*

Mailing Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Address Type

*

Organization/Employer

Type of Practice

*

Specialty of Practice

*

Your Role

*

Provider Kit Contents

The Provider Kit comes with the following materials. You may add extra posters and brochures.

1 - Waiting Room Poster

1 - Exam Room Poster

10 - OUT Maine pens

25 - OUT Maine brochures

We charge a nominal fee to help us cover the cost of materials and postage. Thank you for your support!

Mailed Kit Request: *	Quantity
$20 - Provider Kit
$5 - Extra brochures (bundle of 25)
$5 - Extra Waiting Room Posters (set of 10 posters)
$5 - Extra Exam Room Posters (set of 10 posters)