African Community Educational Materials Printing Request Form

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* 1. What is the name of your organization?

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* 2. What is your organization's address?

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* 3. How many English flip charts would you like to request? (If none, please write 0.) English flip charts can be viewed at https://www.hepb.org/assets/Uploads/Hepatitis-B-Flipchart-for-Community-Education.pdf

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* 4. How many Amharic flip charts would you like to request? (If none, please write 0.) Amharic flip charts can be viewed at https://www.hepb.org/assets/Uploads/Amharic-Translation-FINAL-FLIPCHART-COPY.pdf

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* 5. How many Arabic flip charts would you like to request? (If none, please write 0.) Arabic flip charts can be viewed at https://www.hepb.org/assets/Uploads/Arabic-Translation-FINAL-FLIPCHART.pdf

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* 6. How many French flip charts would you like to request? (If none, please write 0.) French flip charts can be viewed at https://www.hepb.org/assets/Uploads/French-Translation-FINAL-FLIPCHART.pdf

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* 7. How many Swahili flip charts would you like to request? (If none, please write 0.) Swahili flip charts can be viewed at https://www.hepb.org/assets/Uploads/Swahili-Translation-Final-Flipchart.pdf

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* 8. How many copies of the resource Locating Hepatitis B Testing Resources (available only in English) would you like to request? (If none, please write 0.)

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* 9. How many copies of the resource Using the Hepatitis B Flipchart for Community Education (available only in English) would you like to request? (if none, please write 0.)

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* 10. How many copies of the resource Printable Hepatitis B Takeaway Card (available in English, Swahili, French, Arabic, and Amharic) would you like to request? (Please indicate your preferred languages. If none, please write 0.)