Community Partnership Questionnaire

DisposeRx is committed to the eradication of unused medications. As announced at the White House signing ceremony for the historic opioid legislation package known as HR-6, DisposeRx will be working with charitable organizations, faith—based groups and foundations to donate enough of our abuse—deterrent packets to destroy 10 million opioid tablets in home medicine cabinets across the nation.

If you represent a 501(c)3 organization, association, faith—based group or foundation and are interested in applying for a donation of DisposeRx packets, please complete and submit the following form.

– Step 1 of 4

Contact Information

Please confirm your organization’s point of contact’s name, spelling and contact information. Note that none of the answers you provide will immediately approve or decline your request.

Name *

First

Last

Please confirm your contact information.

Address

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

County or Parish of Operation

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Phone Number *

Your title

Email *

Preferred contact method

• Email
• Phone

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Organization Information

Please confirm your organization’s name, spelling and details. This information may be needed for future reference.

Name of Organization *

Mailing Address *

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Is the shipping address the same as the mailing address? *

• Yes
• No

Shipping Address

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Website / URL *

Do you have a certificate of exemption, logo, proposal, or other files you can share?

Click or drag files to this area to upload. You can upload up to 10 files.

Please upload your certificate if available. Files of type .doc, .xls, .ppt, .pdf and under 100MB are accepted. For questions, please contact [email protected].

Social Media Channels

Social Media Channels

Facebook *

• Yes
• No

Facebook account

Twitter *

• Yes
• No

Twitter handle

LinkedIn *

• Yes
• No

LinkedIn account

YouTube *

• Yes
• No

YouTube account

Next

Event, project or program information

Please provide as much detail about your event, project, or program. Note that none of the answers you provide will immediately approve or decline your request.

Are you requesting packets for an event? *

• Yes
• No

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What's the event name?

When is the event scheduled?

Date

Time

How many attendees? (Estimated)

Do you need postcards, flyers or other materials?

• Yes
• No

Is this request part of a project? *

• Yes
• No

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Project Name

Project Status

• Planning
• In progress
• Concluded

Scope of the project

• Local
• Regional
• Statewide
• National

Do you have funding?

• Yes
• Funding has been applied for
• No

Next

Permission

If DisposeRx, Inc. donates time or materials to your event, project or program:

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May we mention you or your program in future research or marketing materials? *

• Yes
• No

Would you be able to complete a survey after the event, project or program concludes? *

• Yes
• No

Anything Else?

Anything else you would like us to know? *

Submit