ADAPT Technical Assistance Request Form - High Intensity Drug Trafficking Areas

Name*

This field is hidden when viewing the form

Title of HIDTA Prevention Representative*

Email*

Enter Email Confirm Email

Phone Number*

Organization/Agency Name*

HIDTA Region, if known

Address

City State / Province / Region ZIP / Postal Code

How can we help you?*

Technical Assistance Category*

If other, please specify:

This field is hidden when viewing the form

File for TA Request

Not required, but you may upload a separate document if needed.

Max. file size: 16 MB.

This field is hidden when viewing the form

Amount of HIDTA funding received for project*

This field is hidden when viewing the form

Target population (check all that apply)*

This field is hidden when viewing the form

Geographic Area of Responsibility*

This field is hidden when viewing the form

Please include a brief description, including goals of the funded prevention project requesting TA (may attach as a separate document if needed)*

This field is hidden when viewing the form

File for Description

Not required, but you may upload a separate document if needed

Max. file size: 16 MB.

CAPTCHA

Email

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