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: ndcc@nd.gov

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