Baby Bottle Campaign Order Form

Your Name / Baby Bottle Campaign Liaison:

Best Phone to Reach You:

Your Email Address:

Church Name:

Church Address:

Church Phone:

Approx. Number of Boxes of Bottles Requested: (40 bottles/box)

1st choice for Campaign Dates: (such as May 3 - June 2)

2nd choice for Campaign Dates:

(Campaigns usually last 4 weeks. More information will be provided once you sign up.)

I would like to pick up the baby bottles at NOVA Pregnancy Center's
Fairfax Office: 3919 Old Lee Hwy, Suite 81-B, Fairfax, VAAlexandria Location: 8800-E Pear Tree Village Dr, Alexandria, VA