Drug Disposal Kit Order Form

Organization Name*
Email
Recipient Name*
First Last
Number of Cases (200 kits provided per case)*
Please enter a number from 1 to 50.
Case Weight: 26 lbs./Each Case Dimensions: 19.5 x 15.5 x 10
Distribution State*
Delivery Address*
Street Address Address Line 2 City State ZIP Code
Contact Phone*
Date Needed By*
MM slash DD slash YYYY
If ordering more than 1,000 kits, do you have a loading dock?
If no, a supply truck with a liftgate will be provided.
If a liftgate is required, will you need an inside delivery?
If a liftgate is required, is there a pallet jack available at the site?
If a liftgate is required, what floor does the inventory need to be delivered to?

Please also indicate whether there is an elevator or not.
Will debris removal be needed (example: pallet, pallet wrap, etc.)?

Submit your signed Memorandum of Understanding to info@chpcommunity.org.