Free Condom Dispensers: Application

The Sexual Health Alliance is currently seeking applications from local community organizations and businesses that are interested in having a free condom dispenser installed at their site. This dispenser will feature the SHA logo and website information and will be regularly filled with latex condoms by one of our coalition members. There are a limited number of dispensers. We will give priority to the locations and agencies that serve at-risk populations and are located in neighborhoods with rates of sexually transmitted infections (STIs).

If you would like a free condom dispenser for your building, please fill out the information below in an email to

Organization/Business name:

Contact person:


Phone number:

Email address:

What services does your agency provide:

Who is your target population:

Why are you interested in having a free condom dispenser installed at your site:

Who at your agency will be responsible for contacting the SHA when the condom dispenser needs refilled?

Do you currently provide condoms at your site?

  •   Yes, they are sold here
  •   Yes, they are provided for free to customers and paid for by ___________
  •   No

Anything else you would like to share with the SHA in this application:

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