HIV Counselling and Testing

Please complete all form fields, especially the ones marked as required.

If you encounter any problems with the application please contact Jolandie Steyl-van Niekerk on 012 816 9000 or mobilerequests@foundation.co.za



Business Type







Details of Person requesting HCT Services






Event Details






Onsite Coordinator






Employee Statistics





Additional Information

Is the HCT event part of a workplace HIV program?


Will the awareness campaign be completed before HCT date?


Is secure parking available for the mobile unit?



Is there adequate space for vehicle and tent village?


Is office space available for conducting HCT Services?


Will refreshments and lunch be provided/available for HCT team members?