Program Name: *

Account-holder Name *

Phone *

Your City: *

Your State: *

Account Holder Email *

Do you distribute Naloxone? *

Who supplies your Naloxone?

Do you purchase items from Smoke Works outside the MAP program? *

Yes
No
In the Past / Not Presently

What items have you purchased from Smoke Works in the past?

Pipes
Test Strips
Outreach Kits
Water / Saline
Accessories

Do you intend to use the MAP Program to: *

Meet all your pipe demands
Suppliment pipes you purchase from Smoke Works
Try pipe distribution for the first time

How much do / can you spend on pipes monthly?

MAP is a great way to spend what you can, and suppliment your inventory without going over budget

Do you keep data on engagement, pipe & syringe distribution? *

Would you share anonymized data on your pipe distribution?

Do you distribute syringes? *

Who supplies your syringes?

Do you distribute test strips? *

Who supplies your test strips?

Has your program distributed pipes in the past? *

Which vendor(s) have supplied your pipes in the past?

NASEN
Amazon
McKesson
Points of Distribution
Remedy Alliance
Next Distro
Smoke Works

Name of previous pipe supplier:

Have any of the following stopped your organization from distributing pipes?

Law Enforcement
Government Order to Cease
Internal Order to Cease
Budget Cuts
Change in Programming
Other

Please provide details about the budget cuts:

Choose which best describe your organization:

Grassroots / Independent / Other
Non-profit
City / State Funded
Newly Forming
Medical
Recovery Services

We love connecting with new, forming, independent mutual aid groups. Please tell us more about your group / outreach

How many individuals do you distribute pipes to weekly?

What is the other closest syringe access point / harm reduction program in your area? *

Do you know of local harm reduction programs unable to purchase pipes? If so, please let us know so we can offer them free pipes, too!

Do you specifically engage particular populations of people who use drugs?

What positive effects of pipe distribution are you seeing among the people you serve? *

Can we use your comments on pipe distribution in print & social media?

YES
NO
Credit me / my program
Leave Anonamyous

Smoke Works' MAP program is limited to pipes only. Select the item & quantity you'd like to request. *

Item Quantity Requested Total Value

Love Roses

—

Misfits (100)

—

Hammer (100 pack)

—

Heavy Stem (72)

—

Long Stems (36)

—

4" Bubble Pipes (100)

—

6" Bubble Pipes (72)

—

I agree to ONLY apply MAP gift card funds to items I selected above *

I understand that orders misapplying gift cards will be canceled, and any necessary refunds to credit or debit cards are subject to a $30 fee *

Would you like to add details about your item / quantity requests? *

Are these supplies intended for no-cost distribution only? *

Thanks for submitting a request!

Thank you for submitting a request.

The Smoke Works team will be in touch within 7 days.

Please email any questions to:

Info@SmokeWorks.org

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