Organization Condom Request - Free Condoms Order Online

Organization*

Type of Organization*

Street Address*

Apartment/Suite Number*

City*

State*
Oklahoma

Zip Code*

First Name*

Last Name*

Title*

Email*

Phone*

Date of Request*

Is your organization currently funded by the city, state, or Federal government to provide condoms?
NoYes

If Yes Please indicate annual dollar amount

Number of Condoms Requested
0- no condoms requested1 case of condoms (about 1000 condoms)2 cases of condoms (about 2000 condoms)

Number of Lubricants Requested
0- no lubricant requested1 case of lubricant (about 1000 lubricants)

By receiving condoms and supplies from the Oklahoma State Department of Health, I agree to the following:
The items delivered through this program will be offered free of charge.All of these items will be distributed only in the state of Oklahoma.Information on the proper use of these condoms will be made readily available to individuals being furnished these items.I will cooperate with staff from the Oklahoma State Department of Health who may be collecting evaluation information through surveys or emails to determine the efficiency and effectiveness of the condom distribution program.To the best of my knowledge, the information above is accurate

Note:

• **We can only ship condoms to Oklahoma addresses.