Free Presentation

Instructions: Complete this form and email it to or mail it to Linda, Breathe Easy Foundation, 3651 North 100 East, Suite 300, Provo, UT 84604.  For assistance call 800-992-7027 Monday through Thursday 10 – 4.

Date _____________________

Name ____________________________________________________________________

Address _________________________________________________________________

City, State ________________________________________ Zip __________________

Daytime Phone ___________________ Email _______________________________

List 3 Possible Dates ___________________________________________________

Desired Time of Presentation __________________________________________

Desired Address of Presentation ______________________________________

Anticipated Number of Attendees _____________________________________

I understand that the educational presentation about the deadly effects of air pollution poison is FREE except for travel expenses.  I understand Breathe Easy will send me confirmation of the date and time, with an estimate of travel expenses, which expenses must be received by Breathe Easy one week prior to the expected date. Thank you.

Signature __________________________________

Helping America Breathe