Account-holder Name *

Phone *

Account Holder Email *

Please select every source that contributes more than 10% to your funding:

Tax deductable donations
Non-deductable donations
Private funding
Public / municipal funding
Grant funding
Sales

How many individuals do you distribute pipes to weekly?

Describe the other harm reduction / syringe exchange services in your area: *

Your City: *

Your State: *

Please describe your current funding/fundraising issues preventing you from purchasing supplies:

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

Preferred payment method:

Online
Phone
Check / money order

Anything else you would like to tell us about your request?

Requests for Material Aid are prioritized to serve folks in hostile enviorniments, lacking connection to harm reduction services, and those often left out of public health approaches: Bipoc, native, queer, indenious people, etc. Please tell us about your specific reach to these and similar communities of people who use drugs: *

Anything you'd like to share about the positive effect of pipe distribution: *

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 Actual Price Total

Love Roses

—

Misfits (100)

—

Hammer (100 pack)

—

Heavy Stem (72)

—

Long Stems (36)

—

4" Bubble Pipes (100)

—

I am an authorized representative of my agencey (selecting this option will add items to cart for later purchase)

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

How much of your order total can you pay for? *

Select 0% if you cannot pay for these items

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

I understand that orders misapplying gift cards will be canceled *

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

Allow up to 7 days for replies to MAP requests.

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

Allow up to 7 days for replies to MAP requests.

SMOKE WORKS MAP PROGRAM

Please Read:

As of 04/22/25: YOU CAN USE YOUR GIFT CARD TO COVER SHIPPING COSTS on items below ONLY

Love Roses

Misfits (100)

Hammer (100 pack)

Heavy Stem (72)

Long Stems (36)

4" Bubble Pipes (100)

Thanks for submitting a request!

Thank you for submitting a request.

Thanks for submitting a request!

Thank you for submitting a request.

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