Condom Request Form | MyIACondoms


To be eligible to receive condoms and other supplies from this system you must agree to ALL of the statements below:

  • Condoms will be given FREE OF CHARGE. No fee will be imposed to individuals accessing these supplies.
  • Condoms will be made available to sexually active persons of any age, including adolescents.
  • Condoms will be available in an area in which individuals can freely take condoms without having to ask for them.
  • Condom expiration dates will be documented upon receipt of each shipment and monitored by the receiving agency.
  • Expired condoms will be disposed of.
  • Condoms will be kept at temperatures within the manufacturer's specifications.
  • I understand that there is no guarantee for the continuation of this program.  
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Harm reduction supplies are not currently available through this system. Upon submission of this order, you will receive information on how to request harm reduction supplies from another program.

This order form is for use by agencies and organizations only.  If you are an individual interested in receiving condoms mailed to you, please use the ONE@Home ordering system.

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