Thank you for your interest in the El Dorado County Health and Human Services Agency (HHSA). If you are interested in requesting HHSA representation at a meeting and/or a presentation on the services we offer, please complete the questionnaire below. A representative will be in contact with you within 48 hours to review and clarify your request. Not all meeting/presentation requests can be honored.

* 1. I would like to request an HHSA Representative:

* 2. The Meeting/Function/Presentation is requested on:

Date / Time

* 3. The meeting location will be:

* 4. The event audience will mainly consist of (check all that apply):

* 5. What topic of services are you interested in hearing about?

* 6. The following audio visual equipment will be available for HHSA use:

* 7. How did you hear about this request form being available?

* 8. How can we contact you?