You are welcome to share this survey with local affiliates of your organization. 

The Immunization Action Coalition (IAC), with funding support from Seqirus, is offering a limited quantity of FREE Flu Vaccine buttons and stickers in English and Spanish to support your flu vaccine promotion efforts this season. 

To receive these supplies at no cost, please PRE-ORDER your buttons and stickers now. Delivery (also at no cost) is anticipated by early October.

Before completing your pre-order, please read the following:
  • Submit a separate pre-order for each shipping location.  
  • Free supplies available through this special program are limited. Additional quantities will be available for purchase online.
  • Once any type of button or sticker is fully pre-booked, we will update the pre-order form to show it is unavailable. If we are unable to fulfill your order for any reason, we will notify you by email.
Questions about completing this form? Email admininfo@immunize.org.

Note: All fields marked with an asterisk (*) are required.

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* 1. This program is for organizations or groups that provide or promote influenza vaccination in the United States.

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* 2. Your First Name

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* 3. Your Last Name

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* 4. Your Email Address

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* 5. Confirm Your Email Address

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* 6. Your Phone Number

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* 7. Your Job Title

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* 8. Organization Name (please spell out)

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* 9. Organizational category (select one):

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* 10. Shipping Contact Name (if someone other than you)

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* 11. Shipping Address (Make sure you list an address where someone will be available to accept the delivery)

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* 16. This program is for organizations or groups that provide or promote influenza vaccination in the United States.

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