IPRC | Request for Services

• 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?		*
• 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:

Request for Services