UV Toolkit Request Form
Organization:
Contact Name:
Address:
Suite:
City: State: Zip:
Is this address: Residential Business E-mail:
Phone: Fax: Date needed:
Please provide a brief explanation of the class, camp, or event that the toolkit will be used at:
Date of event(s)
How many people are you planning to reach?
Please indicate preferred pick up location: Beulah Bismarck Carrington Dickinson Fargo Grand Forks Hettinger Jamestown Linton Mandan Minot Rolla Williston
7/2015 1
Please request at the earliest time possible Maybe checked out for up to 2 weeks from pick up to return Please make arrangements to pickup
TO ORDER:By mail: Comprehensive Cancer, NDDoH, 600 E. Boulevard Ave., Dept. 301, Bismarck, ND 58505-0200By Fax: 701-328-2306By E-mail: [email protected]
7/2015 2