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.

• *PLEASE NOTE: PLEASE DO NOT CLICK THE "SUBMIT" BUTTON MORE THAN ONCE. This causes duplicate orders to be placed. If you do not receive a confirmation notice from the NYS Condom Program within 48-72 hours after placing your request, please either fax your request to us at (518) 473-2873, or email your request attached as a PDF document to NYSCondom@health.state.ny.us. If you have any further questions regarding this program, please contact Tracy Wheatley at (518) 486-1324. Thank you!

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:

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

Although no fixed limits have been imposed on requests, NYSCondom-eligible organizations should explore all options for acquiring safer sex materials. These options include commercial channels and - for New York City-based organizations - the NYC Condom program. NYSCondom was never intended to be the sole source of condoms in New York State - even for organizations whose focus is HIV and STI prevention. Instead, NYSCondom should be seen as a complement to other resources.

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.

Male Condoms

Beyond Seven^® 1,008 per case

Lifestyles^® Assorted Colors, Lubricated 1,000 per case

Lifestyles Ultra^® Lubricated 1,000 per case

TEMPORARILY UNAVAILABLE

Lifestyles Ultra Sensitive^® Lubricated 1,000 per case

Lifestyles Ultra Thin^® Lubricated 1,000 per case

Trojan-Enz^® Lubricated 1,000 per case

TEMPORARILY UNAVAILABLE

Trojan Magnum^® 1,000 per case

TEMPORARILY UNAVAILABLE

Trojan^®/Lifestyles^® Non-Lubricated 576 per case

Female Condoms

FC^® Female Condom 100 per case

Other Latex Barriers

LIXX^® Dental Dams 100 per case

Sheer Glyde^® Dental Dams 100 per case

Finger Cots Case of 1,440

Lubricants

ID Glide^®

TEMPORARILY UNAVAILABLE

Wet^® Light 3ml foil pouch    500 per case