Is your organization currently funded to provide condoms by the city, state, or Federal Government?
A maximum of 2 cases per month can be requested. (1000 condoms per case) The first case will include the Philadelphia Branded Flared Condom, and the second case type can be selected by you.
If 2 cases, please select the type of condoms
Are you requesting lubricant?
Do you understand this online form is for scheduling a pick-up at our South Philadelphia location?
Please schedule a time by calling 215-685-6800. Pick up time are Monday, Wednesday and Friday's before 1 PM at 1930 S. Broad Street, 3rd floor
Do you understand this form is for pickups only?
In signing this Organization Information and Attestation, I am attesting to the following
· The information above is accurate to the best of my knowledge
· The items requested through this program will be provided free of charge
· All of these items will be distributed solely in Philadelphia
· Information on the proper use of these condoms will be made readily available to individuals being furnished these items
· I will cooperate with staff from the Philadelphia Department of Public Health in evaluating this program.
Site Executive

Fax to 215-685-6798.