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2. Your KI tablets in addition to instructions will be mailed directly to you address at no charge.

   Please note that KI tablets will ONLY be mailed to addresses WITHIN the 10 mile EPZ

4. First Name*
6. Last Name*
8. Address*
10. City*
11. State*
12. Zip Code*
14. Number of pills needed 130mg: (1 pill for each occupant over the age of 12)*
16. Number of pills needed 65mg: (1 pill for each occupant under the age of 12)*
18. Contact Phone Number*
19. Email Address*
Leave This Blank:


21. 1. Receive an email copy of this form.
22. Email address

    This field is not part of the form submission.

23. Submit

* indicates a required field