Health Fair and Speaker Request Form

This form is only for requests in Kentucky, Michigan, Ohio and Tennessee.

 

This form is for request purposes only.  We will notify you as soon as possible if we will be able to participate in your event.  Please allow 3-4 weeks for processing. 

*  


*  


*  


*  


*  


*  


   


*  


*  


*  


 

Event Details

*
Question - Required - Type:
Please make between 1 and 2 selections from the choices below.

*  


   


*

(Maximum response 255 chars, approx. 5 rows of text)

*  


*

(Maximum response 255 chars, approx. 5 rows of text)

   


   


*


 
Question - Not Required - If yes, where would you like the materials to be shipped?


   


   


   


   


   


 

If you have any questions, please contact the following:

Emily Lee, PhD, CHES, AE-C
Senior Program Director
6100 Rockside Woods Blvd, Suite 260
Independence, OH 44131
(800) 232-LUNG
Fax:  (216) 524-7647

Word Icon Printable request form

   Please leave this field empty