NEW YORK STATE CONDOM (NYSCondom) PROGRAM

Organization Information and Attestation

Fields with an asterisk (*) are REQUIRED

Organization Information

Individual Authorized to Order Supplies must supply unique email addresses for each person listed




Additional Individual Authorized to Order Supplies must supply unique email addresses




Additional Individual Authorized to Order Supplies must supply unique email addresses




Organization Type: (Check all that apply)*

During which of the following service do you intend to distribute safer sex supplies: (Check all that apply)*

Condom Distribution Information

Identify populations to which you anticipate 10 percent or more of safe sex supplies ordered through NYSCondom will be furnished. (Check all that apply)*

How will you distribute these supplies? *

What are the multi-county regions you will be distributing supplies in?(Check all that apply)*









*What are the primary counties in which you will be distributing supplies?(Select at least one)






Knowledge of NYSCondom Program

How did you learn about this program for free condoms?*

Attestation*

Executive Director or Designee Contact Information