AIDS Research - Priority Notification Form

AIDS Research Alliance PRIORITY NOTIFICATION FORM Please complete the following fields and click on the submit button only once. ARA maintains a strict policy on confidentiality, we will never share or sell your contact information. Additionally, please submit only information about yourself and not that of others.
First Name	Last Name
Postal Address			City	State	ZIP Code
Daytime Phone	Evening Phone	Cellular/Pager
Gender	Ethnicity	How should we contact you (select all that apply)
		Email		Phone	Postal Mail
Email Address		Email Address (repeat to insure accuracy)

How did you originally hear about AIDS Research Alliance?
	Search Engine
	Friend
	ARA Study Volunteer
	Community Event
	Advertising
	Referral from other agency
	Other (please state)

Are you interested in any of our currently enrolling studies? if yes which one?
Do you want to receive a free subscription to Searchlight and Spotlight, our periodic newsletters? Note: all PNP mailings are sent out in a confidential envelope, which does not contain our name, only our initials & mailing address.				Yes	No


Click below to submit or print out the form and fax it to us at 310.358.2431.