Request Form: Immunization Advocacy Resource Kit

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Request Form

Immunization Advocacy Resource Kit

This is NOT an online order form, please fill in the fields, then print it, and fax or send to:
Gates Children’s Vaccine Program, PATH, 4 Nickerson Street, Seattle, Washington 98177, USA Fax: (+1 206) 285-6619

The GAVI Immunization Advocacy Resource Kit contains a number of printed documents, a video, and a CDROM. Due to expense, only a limited number of the Kits can be produced and distributed. Most of the kits were distributed to staff of GAVI partner organizations and to Ministry of Health personnel in Africa, Asia, and Latin America in June 2001, but some are still available. Please answer the following questions so that we can determine your eligibility for receiving one of the remaining Kits:
What is your job? How will you use the Kit in your day to day work?
Why do you need a hard copy of the Kit instead of downloading and printing the relevant files from the website?
Are there any particular Kit materials that you need in hard copy? Which ones? (We may be able to send you those materials, even if we can’t send you an entire Kit.)
What language Kit would you prefer?	English French Spanish
What video format is commonly used in your country?	NTSC PAL SECAM
Where should we send the Kit?
First name
Last name
Title
Organization
Street address
City
State/Province
Country
Zip/Post code
Please also provide this information:
Your telephone:
Your fax:
Your email:

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