Take Control Philly Condom Site Application

Contact*

First NameLast Name

Organization*

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

YesNo

Type of Business*

Site Executive*

Address*

Street Address

Street Address Line 2

CityState

Postal / ZIP CodeCountry

Business Hours

e.g. Mon/Tue: 7:00 a.m. to 4:30 p.m., Wed-Fri: 7:30 a.m. to 8:00 p.m.

Email*

example@example.com

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

A maximum of two cases per month can be requested (1,000 condoms per case). The first case will include the Philadelphia Branded Flared Condom, and the second case can be selected by you.

How many cases are you requesting?*

12

Second Case*

Philadelphia Branded Flared CondomsRibbed CondomsExtra Large Condoms

Are you requesting lubricant?*

YesNo

Do you understand this online form is for scheduling a pickup at our South Philadelphia location?*

YesNo

Please schedule a time by calling 215-685-6800. Condoms may be picked up Monday, Wednesday and Friday before 1 p.m., at 1930 S. Broad St., 3rd Floor.

Do you understand this form is for pickups only?*

YesNo

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 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.
I will cooperate with staff from the Philadelphia Department of Public Health in evaluating this program.

Signature*

Date*

Date

This form is only for scheduling a pick-up at our South Philadelphia location. Please review your responses above. If you have any issues submitting this form, please contact charles.postell@phila.gov.