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:

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

1st choice for Campaign Dates: (such as May 10 - June 9)

2nd choice for Campaign Dates:

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

I will pick up the baby bottles at NOVA Pregnancy Center's
Fairfax Location: 10380 Democracy Lane, Fairfax, VAAlexandria Location: 8800-E Pear Tree Village Drive, Alexandria, VA