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Condom Distribution Form
If you or your business is interested in being a condom distribution site, please fill out the form below.
**Must be in the West TN Region** **This excludes Tipton, Shelby, and Fayette County**
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* Indicates required question
Name of Business
*
Your answer
Address
*
Your answer
County
*
Your answer
Business Hours
*
Your answer
Contact Information
*
Your answer
Where would the condoms be held?
*
Front Desk/Counter
Bar
Given upon request
Other:
Required
What Condoms would you like?
*
Platinum XL
Unique Packaging
Super Sensitive
Regular Fit
Female/Insert Condoms (limited supply)
Specialty Condoms (ribbed, studded, etc.) [limited stock]
Other:
Required
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