Application Form for Narcan® Emergency Box at Your Facility
Instructions: Please complete and submit the form below.  If your application is approved, we will contact you when your Narcan® Emergency Box is ready to be picked up.  
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Facility Name (where box would be placed) *
Address *
City/Town *
State *
Zip Code *
Facility Website Address
Contact Person: Full Name *
Contact Person: Position/Title *
Contact Person: Phone Number *
Contact Person: Email Address *
Would your establishment be interested in serving as a public distribution point for naloxone in the future? *
Electronic Signature Agreement                                          
1) I confirm that I am an authorized representative of the establishment listed above.
2) I agree to the following statements:
Site personnel will complete necessary training for naloxone.
Site personnel will visually inspect the Narcan® Emergency Box and resupply as needed.
Site personnel will refer all interested individuals to community Narcan trainings.
By checking checking the box below and providing your electronic signature, you agree to the above statement. *
Required
Electronic Signature *
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