Material Request Form


Complete the form below at least 4 weeks before the planned event. Allow 2 weeks for delivery.

Please note that, due to a very large volume of requests, we are absolutely unable to fulfill any requests for events being held less than 4 weeks from today. We apologize for this temporary situation.

At this time, we cannot provide materials to locations outside the United States and we cannot ship to P.O. boxes
.


Spread the Word starter kits include:

  • "Take the Test" pledge cards.
  • HPV Educational brochures.

Coordinator Information
Coordinator name
Address
Address2 (optional)
City
State
Zip
E-mail
Phone ext.
 

Event Information    

Briefly describe the planned event (health fair, club meeting, church program, etc.) and how you expect to use the materials.


Date of event
About how many people are you expecting to attend?
What is the average age of expected attendees?

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