Juneteenth 2023 Health Service Registration Form
Website: juneteenthcelebrationnyc.org      Email: juneteenthcelebrationnyc@gmail.com

Street Fair: 116th Street between Malcolm X Blvd (Lenox Ave) & 5th Avenue
Date: June 17th, 2023

**Vendor set-up is 9:00AM and closing time is 5:00PM**
**Vendors must provide their own tables and chairs**
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Organization/Business Name *
Select below if your organization will set up a booth or have a van: *
Required
Please describe the services your health organization will be providing: *
Contact Person *
Email *
Street Address *
City, State, Zip *
Phone Number *
Please complete this form by June 10th. For more information, please contact Mr. Ade A. Rasul at (212) 662-2200/01 *
Required
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