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Educational Material Request Form (payment)

 

Komen North Carolina Triangle to the Coast gets many requests for educational material; unfortunately, we can not fill all requests. Only requests from individuals or organizations in our service area can be considered. Our Affiliate service area covers 29 counties including: Bladen, Brunswick, Caswell, Chatham, Columbus, Duplin, Durham, Edgecombe, Franklin, Granville, Halifax, Harnett, Johnston, Lee, Moore, Nash, New Hanover, Northampton, Onslow, Orange, Pender, Person, Pitt, Sampson, Scotland, Vance, Warren, Wake, and Wilson.

• Please give at least two weeks lead time for your request or you may not receive materials.

• There is a limit of 25 copies of each item and a max of 75 copies total.

We do our best to fill all requests for material and will give prompt notification if we cannot. For more information, please contact info@komennctc.org.

If you are looking for pink ribbons, bracelets, or other branding items you may order them online from Shop Komen where 25% of your purchase price will be donated to Susan G. Komen North Carolina Triangle to the Coast.

1. Contact Information

*

Name:

 

 

   

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City/State/ZIP:

 

    

 


*2.
Question - Required - Date of Event:




*3.  


*4.  


*5.

6.  


*7.
Question - Required - Please select the material you would like from the options below. You are only able to select 3 options and will be provided 25 copies of each option totaling to a max of 75 copies.
Please make between 1 and 3 selections from the choices below.

*8.


9.  


 

Participant Information:

*10.
Question - Required - Age range of participants (check all that apply):
Please make at least 1 selection from the choices below.

*11.
Question - Required - Primary audience (check all that apply):
Please make at least 1 selection from the choices below.

*12.  


   Please leave this field empty