Name
Chapter Name
Address
City State Zip

Number of samples requested

Number of total members in chapter
Average number of members at meetings
Does your chapter have a newsletter? yes no

If so, what is the frequency?
Newsletter Contact Name
Phone Number

A word about privacy: The information you provide here will be held in the strictest confidence. We will not sell your name to others or do anything with it other than use it for Ostofresh. If you have further concerns or questions regarding privacy, please e-mail us: request@ostofresh.com