Avian Flu Request for Presentation

When you have completed the form, EITHER: 1. Save it and email as an attachment to the Center at Center@bioprepare.org OR         2. Print the form and fax to 402-552-2769

Requested presentation date(s):                Time:

for: (name of group or organization):

To be presented at (location/building/organization etc):         City:          County:        State:         Zip:

Audience (check all that apply):  general public        university       high school    elementary school  civic or business organization   church    Healthcare institution/Hospital, etc. other

YOUR contact information:

name:         phone:

alternate phone:         email:

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