Safety On Wheels Community Presentation

If you would like to host a Manitoba Public Insurance presentation, please complete the following form and submit, using the SEND button below.

Any required fields are noted with an asterisk (*).

*Activity requested:
*Requesting Organization:
*First Name:
*Last Name:
*Address:
*City/Town:
*Postal Code: (example: R3C4A4)
*Telephone Number: () -
Fax Number: () -
*Email Address:
*Event:
*Event City/Town:
Presentations are available from May 9 to August 25.
*Preferred Date:
1st Alternate Date:
2nd Alternate Date:
*Time of Day:
*Target Audience:
*Estimated Attendance:
*Facility Provided:
*Type of Promotion:

(Please check all that apply) 		School Announcement
Flyers
Posters
Newspaper Ads or News Coverage
Television Ads or News Coverage
Other (specify in Additional Information area)

Additional Information:



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