Buyers Club

Application

The Buyers Club (BC) uses co-op buying power to acquire the lowest syringe prices for large and small exchange programs alike.

Through a contractual agreement with select manufacturers and wholesale providers, NASEN offers low-cost non-government prices for harm reduction supplies nationwide.

To take advantage of our purchasing abilities and to order supplies through our Buyers Club, please complete the application below. Please note: all applications must be completed in full using a non P.O. Box ship-to address and current contact information. All applicants will receive a follow-up email with welcome information. Please submit only one application per program. If your program has questions or requires additional information please contact a Buyers Club team member at Buyersclub@nasen.org or at (253) 213-3221.

Identification

Program Name*

DBA/AKA

Start Date

Website

Legal Status

Legal Illegal/Tolerated Illegal

Site Contact

First Name*

Last Name*

Email*

Phone*

Fax

Hours

Address*

City*

State*

ZIP Code*

Billing Contact

First Name

Last Name

Phone

Address

City

State

ZIP Code

Shipping Contact

First Name

Last Name

Phone

Address

City

State

ZIP Code

Qualifications

	Yes	No
Are you a syringe exchange, syringe access and/or syringe service program?	Yes	No
Are you with a health department or university?	Yes	No
Do you have a funding letter, award letter, contract or agreement for funding that states there is money for SSP services? Contract/Agreement (PDF)	Yes	No
Are you an overdose prevention program?	Yes	No
Are you a drug user's union?	Yes	No
Do you have a physician license? Physician License (PDF)	Yes	No
Do you have a tax-exemption certificate? Tax-exemption (PDF)	Yes	No
May we contact you for research purposes?	Yes	No
May we publish your information in the NASEN map/directory?	Yes	No
May we publish your information in the American Founation for AIDS Research map/directory?	Yes	No
May we release your information to the Dave Purchase Survey?*	Yes	No
Does your program have a mobile unit?	Yes	No
Is your program delivery only?	Yes	No

Submit

I CERTIFY* that the facts contained in this application are true and complete to the best of my knowledge and understand that, if accepted into the Buyer's Club, false, misleading or incomplete statements on this application shall be grounds for dismissal.

Leave this field blank:

* The Dave Purchase Survey, formally known as the Beth Isreal Medical Survey, is currently the only collection and source of national syringe exchange data for the United States. This survey is a key component and tool in lifting the federal ban on funding syringe exchanges.