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We provide a variety of consulting and data analysis services to support your needs...
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Request for Services
Thank you for choosing the Indiana Prevention Resource Center.
Please provide us with the following information so we can begin assisting you as soon as possible.
(
*
denotes required field)
• Organization Name:
*
• Contact Person:
*
• Title:
*
• Phone Number:
*
ex) 123-456-7890
• Fax Number:
ex) 123-456-7890
• E-mail:
*
• Mailing Address:
*
• City:
*
• State:
*
• Zip:
*
• County:
• Best way to contact you?
E-mail
Phone
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Mail
*
• Describe the assistance
needed:
*
Evaluation
PREV-STAT
Training
Technical
ATOD Survey
Other
• Please provide the specifics and details of your project. Include any grant deadlines or requirements that may apply.
• Have you used the IPRC before?
Yes
No
• Does your organization serve Indiana?
Yes
No
• Is the organization tax exempt
under IRS code 501 c 3?
Yes
No
• How did you hear about the IPRC?
Friend or Coworker
IPRC staff member
Media
Training/Presentation/Exhibit
Brochure
Web / Search Engine
Other:
We are committed to providing you with the highest level of customer satisfaction possible.
If for any reason you have questions or comments, we are delighted to hear from you.
Call our Indiana toll-free number at 800-346-3077 or send us an email to
drugprc@indiana.edu
.
We look forward to working with you.
If you prefer, please download
MS Word
or
PDF
file and send back to us via e-mail or fax.