Technical Assistance Request Form - California Rural Indian Health Board

Name*

Title/Position*

Organization*

Email*

Phone*

As we have questions, what is the best way to get a hold of you?*

Same email as above?*

Preferred Contact Email*

Address*

Street Address City State ZIP Code

Same phone as above?*

Preferred Contact Phone*

Type of Assistance Requested*

Topic of Assistance Requested*

Select all that apply.

Other, Please Describe*

Brief Description*

e.g., how will the technical assistance benefit your organization/program/community(ies)

Which tribes will benefit from this technical assistance request?*

Please list all tribes or tribal consortia that this request will serve.

When does the technical assistance request need to be complete?*

How did you hear about CTEC services?*

e.g., Indian Health Service, California Rural Indian Health Board, Inc., Indian Health Program, etc.

Questions? Email us at epicenter@crihb.org or give us a call at (916)929-9761 ext. 1550.

Phone

This field is for validation purposes and should be left unchanged.