LivLyme and TickTracker Materials and Event Support Form

Outreach Supplies and Event Support

Would you like to order outreach supplies or request support for an event? If so, please complete the following form.

Do you have a conference, meeting, fair, educational forum, trade show, or you just want to help spread the word about LivLyme and/or TickTracker?

We can send you a LivLyme Info Kit (LivLyme Outreach materials) or TickTracker Info Kit (a TickTracker postcard stand, TickTracker postcards, stickers and bracelets).

Question Title

* 1. Today's Date

Date / Time

Date

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* 2. I would like to request informational materials for

LivLyme Foundation

TickTracker

Both

I do not want materials

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* 3. Materials requested (if applicable check all that apply)

LivLyme brochures/cards

TickTracker cards (25/pack)

TickTracker card stand (will hold TT cards)

TickTracker Stickers

Silicone Bracelets (Latex Free)

Other (please specify amounts or additional requests)

Question Title

* 4. Please tell us how you plan to use the materials. Examples include office waiting room, conference outreach table, event etc.

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* 5. I would like to request someone to attend or speak at an event. Please check all that apply.

TickTracker Representative

LivLyme Representative

Olivia Goodreau

Presenter/Speaker

Outreach Table

I do not need/want someone to attend an event

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* 6. Please describe event: Name, Purpose, Number of Attendees expected etc.

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* 7. Date of event, if applicable

Date / Time

Date

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* 8. Date materials requested by, if applicable

Date / Time

Date

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* 9. Contact Information

Billing Contact Name

Company/Business Name

Address *

Address 2

City/Town *

State *

ZIP Code *

Country

Email Address *

Phone Number *