This government document is issued by Department of Public Health, Georgia Immunization Registry for use in Georgia
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https://www.google.com/url?client=internal-element-cse&cx=450907bf5042c4844&q=https://dph.georgia.gov/sites/dph.georgia.gov/files/WicPM/forms/WIC%2520District%2520Request%2520to%2520Purchase%2520Form.pdf&sa=U&ved=2ahUKEwju-I7QtPKKAxVVU6QEHYPIO0M4MhAWegQIChAC&usg=AOvVaw1PLlJKgY0EMH8Usoe_G5XQ