- Before you begin, please ensure that your agency meets the eligibility requirements to become an affiliate Community Naloxone Program.
- We recommend that you first read through this entire form and gather the necessary components for your application before filling it out.
- If your program belongs to an agency/organization with multiple locations, please submit an application for your entire agency/organization rather than an individual application per agency program site.
- You must choose a primary address for deliveries under the contact information section. However, you may add as many additional delivery locations as you would like by selecting “no” for Question 5, and then listing additional addresses under Question 5a.
Once your application is submitted, it will be reviewed by the Bureau of Substance Addiction Services (BSAS) for completeness and eligibility. BSAS staff will contact your designated CNP Coordinator with any follow-up questions or next steps.
BSAS is currently offering naloxone at no cost to CNP programs, so long as funding remains available for this resource by state and federal funders. Please clearly indicate that you want free naloxone by selecting “yes” on question 3. Only select “no” if your agency is committed to purchasing the naloxone you are ordering.