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Program Name *

First Name *

Last Name

Email *

Phone *

Shipping Address: Line 1 *

Shipping Address: Line 2

City *

State/Prov/Region *

Postal/Zip *

Country *

Program Type *

Approx. Organization Budget (not inclusive of in-kind) * *

Does your project need fiscal sponsorship? *

Yes, we need support with administrative things like payroll and grant management
Yes, we need 501c3 umbrella status so that we are eligible or grants and charitable giving
I would like someone to reach out to me with more information about sponsorship.
No, we do not need fiscal sponsorship support.

Is your program exempt from state sales tax? *

Do you have a local sales and use tax exemption certificate? If so, attach a copy here.

This is not your 501(c)(3) letter of determination

Does your project need a physician to sign on for sterile water and naloxone purchases? *

Please attach a copy of your physician's license *

Sometimes folx reach out about partners programs or for services in their area. May we release information about your program to the following? *

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We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

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