Material Request Form

Complete the form below at least 4 weeks before the planned event (ideally). Allow 2 weeks for delivery. Note that all requests will be confirmed. At this time, we cannot provide kits to locations outside the United States.

Spread the Word starter kits include:

  • "Take the Test" bracelets and pledge cards.
  • Educational brochures.
  • digene HPV Test lip balms or purse mirrors, for larger events expected to be attended primarily by women over 30 years of age.

Coordinator Information

Coordinator name:
Address:
Address2 (optional):
City:
State:
Zip:
E-mail:  
Phone:   ext.
eg. (xxx) xxx-xxxx

Event Information    

Briefly describe the planned event (health fair, club meeting, church program, etc.):

Date of event:  /  / 

About how many people are you expecting to attend?

What is the average age of expected attendees?

Will you have equipment to show a DVD?

Language preference for materials?

 

Once your event has been held, theHPVtest.com will contact you with a brief survey to find out how it went and possibly to post an event success story on the Web site.