HIV Testing Day Activity/Event Submission Form

Fields marked with * are mandatory:

Organization:

Web site:

Phone Number:

(Use xxx-xxx-xxxx format.) Ext:

Fax Number:

Contact Name:

Contact Phone:

* (Use xxx-xxx-xxxx format.) Ext:

Contact E-mail:

NHTD Event

Name:	*
Description:
Start Date:	*	End Date:	Event Time:	*
(Use mm/dd/yyyy format.)		(Use mm/dd/yyyy format.)

Address: *
City:	State:	ZIP:

Will onsite testing be provided? Yes No

If yes, will rapid test be provided? Yes No

Audience(s) served:

Disclaimer: Events submitted will be listed on the Web site at our discretion. We reserve the right to not list events. Please allow at least 3 business days from date of submission for events to be posted.