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Department of Health Services

Verify Shipping Information

First Name: *
Last Name: *
Company:
Address Line 1: *
Address Line 2:
City: *
State: *
Zip Code + 4: *	* Zip + 4 is required for shipping.

	Shipping Method
	Fedex USPS USPS Counter UPS 2nd UPS Inter-D

Ship Inter-D:

Enter Contact Information:

*	Required Fields
First Name: *
Last Name: *
Company Name:
Address Line 1: *
Address Line 2:
City: *
State: *
Zip Code + 4: *
Phone Number: *
Tax Exempt:	Tax Exempt #:
Email Notification:
Update Shipping Address

Enter Login Information:

Email: Update Email *
Password: Update Password *

Employees who work for a state agency must provide the following information:
Wisconsin State Agency:
Use Code:

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