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 and we cannot ship to P.O. boxes.

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.