Mobile Bus Form Please enable JavaScript in your browser to complete this form.We provide Free HIV Mobile Testing at any of the following Cities/States: (Please select one)* *Boulder City, NVHenderson, NVLas Vegas, NVNorth Las Vegas, NVName of Event: *Name *FirstLastPhone *Email *Date / Time of Event *DateTimeAddress of Event *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeLoad In Time *Start Time of Event *End Time of Event *Load Out Time *Type Of Event *Club/BarCommunity Health FairSchoolCommunity CenterMusic/Sports FestivalOtherWill Parking Be Available? Our Mobile Unit is 10 Ft Wide x 20 Ft Length *YesNoWill The Event Require a Certificate Of Liability? *YesNoApproximately How Many People Will Want a HIV Test? *Event Information/SummaryAttach Event Flyer (Optional) Click or drag a file to this area to upload. Submit Form