Condom Distribution Application

Date:*

Days of Operation:*

Select all that apply.

Hours of Operation:*

Organization Name:*

Contact Name:*

Alternate Contact:

Phone Number:*

Alternate Phone Number:

Email Address:*

Alternate Email Address:

Address:*

City:*

State:*

Zip Code:*

Type of Organization:

Does your organization agree to accept and fulfill walk-in requests from members of the community for condoms? :*

Yes No

Can the Florida Department of Health list your organization or site as a location for free condoms? :*

Yes No

Does your organization agree to the following?

Your organization will provide condoms in an on-site location that is visible and accessible to clients?*

Yes No

Your organization will provide condoms in an on-site location that does not expose condoms to direct sunlight, flourescent light, moisture, and/or extreme high or low temperatures. The acceptable range is betweeen 59 - 86 degress Fahrenheit.*

Yes No

*No bathrooms please, as the moisture can compromise condom quality.