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New York State Condom (NYSCondom) Program

Terms of Use

By placing this order, I agree to each of the following without reservation:

All items ordered through this program must be provided free of any charge and without any requirement or obligation on the part of those persons to whom my organization provides these items.
All of these items will be distributed solely within New York State.
The staff, volunteers and other agents of my organization may not knowingly furnish these items for re-distribution outside New York State.
Information on the proper use of condoms, either through printed materials or other instruction, will be made readily available to those individuals to be furnished these items.
I will cooperate with staff from the New York State Department of Health in evaluating this program.

I Agree
I Disagree

Do not complete this request form unless a New York State Condom Program Organization Information and Attestation (OIA) has already been submitted which specifically authorizes you to make NYSCondom requests. You must specify below the e-mail address that was provided on the OIA.

Your Contact Information

First Name:

Last Name:

Title:

Organization:

Address Line 1 : (Cannot be a P.O. Box)

Address Line 2:

City:

State:

Zip Code:

Phone Number: Extension:

Fax Number:

E-Mail Address:

Shipping Information

Shipping Address is the Same as Contact Address

First Name:

Last Name:

Title:

Organization:

Address Line 1: (Cannot be a P.O. Box)

Address Line 2:

City:

State:

Zip Code:

Phone Number: Extension:

Fax Number:

Order Requests

Indicate your order on the form below. The quantity specified should be the number of cases you would like for each item. If, for example, you want to order 10,000 lubricated Lifestyles^® condoms, you should indicate 10 in the Quantity/Cases field, because there are 1,000 of these condoms in each case that is shipped.

Male Condoms
Female Condoms
Other Latex Barriers
Lubricants
Product Descriptions

NOTICE: We make no assurances that we have the itemized products in stock. We reserve the right to:

Deny any order in whole or in part;
Adjust the quantity of orders; and
Substitute items.

In offering these products free to the public, we are not making any endorsement of them nor are we making a qualitative assessment of them as compared to other products that may be commercially available.

Please allow approximately 3-4 weeks for the initial order.