Seminar Kit Order Form

Everything needed to publicize and host Take Your Best Shot is conveniently packaged in one box and will be shipped directly to you at no charge. The kit will contain enough materials for 50 participants. Millennium will only use the information you provide to send you the kit requested.

* Required Field

Title

First Name *

Last Name *

Email Address *

Phone Number *

Support Group Name *

Website

Please Indicate Setting for TYBS Seminar *
Support Group Senior Center VA Hospital
Support Group Name, Senior Center Name or VA Hospital Name *

Address *
Street Address		The Take Your Best Shot kit is only available in the United States.
Address Line 2
City	State / Province / Region
Postal / Zip Code
Shipping Address different than Seminar Location

Address *
Street Address	The Take Your Best Shot kit is only available in the United States.
Address Line 2
City	State / Province / Region
Postal / Zip Code

Estimated Number of Attendees *

When do you plan on holding your seminar? *

Best days of week/times of day to contact seminar host *

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