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 service area (city, state) *

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

Do you agree to pay shipping costs for your order? *

Yes
Unsure

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?

For example: "50% off would keep me stocked and my people safe" or "We're broke until the next grant comes through, can you comp these items?"

This grant funded project offers free supplies to groups reaching populations disproportionatly effected by overdose: BIPOC, Sanish-speaking, Latino, Native, Pacific Islanders, LGBTQ, etc. If your harm reduction efforts are focused on reaching a specific population of people who use drugs, please describe below: *

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

Item Quantity Requested Actual Price Total

—

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

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

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

Select 0% if you cannot pay for these items

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.

Please Read:

This is a grant funded effort to minimize harm to those disproportionately affected by the war on drugs. Priority is given to organizations without funding; groups engaging communities of color; BIPOC led organizations; and those operating in especially hostile environments, in service deserts.

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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