* Do not include sensitive information
Have an event and would like to have us come do some HIV testing at no charge with our mobile HIV test van? Just complete this form and we will respond to see if we can help!
Name of Contact Person at Event
Contact Number of Person at Event
About The Event
Location of the Event*
Name of Event*
Date of Event*
Detailed Summary of Event/Special Requests
Estimate # of People Attending*
Estimate # of HIV Tests*
Will a parking space be reserved?