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* 1. Please provide your information below:

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* 2. County where the Narcan/Deterra will be distributed:

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* 3. Number of Narcan units needed?

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* 4. Number of Deterra bags needed?

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* 5. Please provide a brief description of why Narcan/Deterra request is being submitted.

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* 6. Date of event/strategy the Narcan/Deterra is needed:

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