Center For Minority Health
National Minority Health Month 2008
Vendor Request Form (VRF)

Type of Vendor:

Health Information Only (What type of information):
Selling Goods & Wares* (What kind of goods & wares):
Exhibit/Activity (Brief explanation):
Information & screening (list types of screening)
Miscellaneous Activity (Brief explanation):

Are you a research study?

If Yes, have you presented at the CRAB?

If you checked that you ARE a research study please fill in the following area. If you are NOT a research study, please skip this and move to the next portion of the request form.

Please provide information about research study (Please include the PI & contact information):

Space is limited and tables will be available on a ‘first come first serve’ basis.

Sat 4/12 Premiere Event –Kingsley Association Noon - 6pm

Name

Mailing Address

Please check if you are a member of CMH

CRAB
Community Learning Collaborative
Health Disparity Working Groups

No request is granted and official until you have received a written confirmation from the Center for Minority Health!

*All vendors selling goods and wares will be charged $50/table (6 foot with 2 chairs). This fee can be waived by your donation of gift items valued at $50. All other vendors will receive one six foot table & 2 chairs for their booth space, at no cost.

Please indicate your needs below and every attempt we will be made to accommodate your request.
Additional tables or chairs are available for a fee of $50.00. Each vendor will receive a letter confirming participation in the event with details regarding set-up instructions and the number of tables allotted.

	# of Additional Tables		# of Additional Chairs
Electrical Outlet at booth (If available)	Yes No

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If you have any questions or problems with the format of the survey itself, please feel free to contact Charlotte Baker at (412) 624-5665 or cbaker@cmh.pitt.edu.