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* 1. Name of Organization/Agency

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* 2. Contact Name

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* 3. Email

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* 4. Phone Number (Mobile or Office)

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* 5. Agency Website

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* 6. Type of Site

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* 7. NCSD Member Type

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* 8. What populations do you primarily serve? (Check all that apply)

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* 9. Number of condoms you would like to receive (boxes come in 1000 condoms each)

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* 10. NCSD will be using the latest CDC-published surveillance data to look at STD morbidity in your state or county. Please describe local factors that we should consider in selecting your site for donation.

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* 11. How did you learn about Condom Connect?*

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* 12. Are you currently receiving TrojanTM Brand Condoms at discounted public health pricing?

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* 13. Please describe the location of your storage site.

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* 14. Does the storage facility have a loading dock?

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* 15. Please complete information for the person and place specifically responsible for receiving deliveries and storage in the following questions. It is imperative that NCSD + the delivery company can verify and reach out to coordinate a delivery.

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* 16. NCSD and TrojanTM Brand Condoms may want to publish tweets or Facebook posts about this donation. Would it be feasible to promote our partnership with your health department or organization?

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* 17. What questions do you have for NCSD staff about the Condom Connect program?

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