If your municipality is interested in receiving drug deactivation resources, please fill out the application below. The AmerisourceBergen Foundation will respond within 30 days. Questions on the application can be directed to ABCFoundation@amerisourcebergen.com.
Drug Deactivation Resources will be donated utilizing AmerisourceBergen's network of distribution centers. This will be based on location of the municipality requesting resources and the quantity requested. Municipalities will have the discretion to determine how to distribute these resources once received from AmerisourceBergen Foundation. In addition, municipalities are encouraged to work with partner organizations to determine the best approach based on local needs.

* 1. General Information

* 2. Category of Organization

* 3. Primary Contact Information

* 4. State your mission.

* 5. Has your organization/municipality already began work/been involved in work to combat the opioid crisis, either internally or in partnership with other organizations?

* 6. If yes, please summarize your work, programs and timing in regards to the opioid crisis.

* 7. Please summarize how your mission aligns with the work being done to combat the opioid crisis.

* 8. Please detail how you plan to utilize and/or distribute the drug deactivation resources in your community. Please be as specific as possible.

* 9. Total amount of drug deactivation resources requested (note: resources provide safe, on-site disposal and can distributed to individuals or households)

* 10. Projected duration of utilization/distribution of drug deactivation products:

* 11. How will this donation from the AmerisourceBergen Foundation be recognized?

* 12. Is there an opportunity for AmerisourceBergen associates to participate in or volunteer at an event?

* 13. Is this organization/municipality governed or managed by a board of directors, council or committee?

* 14. If yes, please list the chairman and board members.

* 15. What is your role in this request?

* 16. Are you currently a customer of an AmerisourceBergen Corporation entity or have you worked with AmerisourceBergen in the past?

* 17. If yes, what is the name of the organization?

* 18. Is your organization currently engaged in discussions regarding the purchase of products or services from an ABC business entity?

* 19. Is this organization/municipality open to participate/be included in proactive media relations efforts (i.e. press release) promoting the donation from the AmerisourceBergen Foundation?

* 20. If yes, is this organization/municipality open to supporting the Foundation’s media relations effort via its own resources?