Is your organization currently funded to provide condoms by the city, state, or Federal Government?
NoYes
A maximum of 2 cases per month can be requested. (1000 condoms per case) The first case will include the Philadelphia Branded Flared Condom, and the second case type can be selected by you.
If 2 cases, please select the type of condoms
Are you requesting lubricant?
NoYes
Are you picking up condoms?
NoYes
If yes, please schedule a time by calling 215-685-6800. Pick up is at 500 S. Broad St.
Do you want the condoms delivered?
NoYes
Please note deliveries occur on Fridays of every week
ATTESTATION
In signing this Organization Information and Attestation, I am attesting to the following
· The information above is accurate to the best of my knowledge
· The items requested through this program will be provided free of charge
· All of these items will be distributed solely in Philadelphia
· Information on the proper use of these condoms will be made readily available to individuals being furnished these items
· A window sticker identifying this organization as a free condom distribution site will be placed prominently in the window.
· I will cooperate with staff from the Philadelphia Department of Public Health in evaluating this program.
Site Executive

If you would prefer to fax this form, please download and save this form and fax it to (215) 685‐6798