IDPH/VIPS Gun Lock Request Form

IDPH/VIPS Gun Lock Request Form

Thank you for your interest in distributing gun locks in your community. By addressing firearm safety, we will work Together for a Safer Illinois.

The Illinois Department of Public Health (IDPH) Violence and Injury Prevention Section (VIPS) is pleased to share the availability of gun locks to community organizations through a partnership with the U.S. Department of Veteran Affairs (VA). IDPH/VIPS appreciates the support from the VA to supply cable gun locks as a strategy to promote firearms safety.

Please complete the following information, to inform IDPH/VIPS of how many gun locks are needed, where to send them, and how they will be distributed.

Today's Date*

I. Contact Information

First Name*

Last Name*

Title*

Agency Name*

Agency Address*

Address (2nd line)

City*

Select or enter value

State

Zip Code*

Phone Number*

Phone

Email Address*

II. Requesting Locks

NUMBER OF BOXES REQUESTING (100 LOCKS PER BOX)*

Gun locks are packaged 100 per box. The boxes are 27 lbs. each and 11” cubed. Please place your order two weeks prior to your event to allow time for delivery; large orders may take longer. The locks will be shipped directly from the VA.

How many boxes are you requesting?

III. Shipping Information

Shipping Information*

Ship boxes to the contact listed above.

Please note- the gun locks cannot ship to P.O. Boxes. Please provide a physical mailing address.

Select or enter value

Ship To First Name

Ship To Last Name

Agency

Shipping Address

Shipping Address (2nd line)

Shipping City

Select or enter value

Shipping State

Shipping Zip Code

Shipping Phone Number

Phone

Shipping Email Address

IV. Distribution Plan

DISTRIBUTION PLAN*

Please provide a brief outline of your plans for distribution (e.g., distribute at a special event, through specific programs in your office, as part of counseling sessions).

Event or Start Date*

Event Name*

Link to Event Webpage

If applicable.

How many locks do you anticipate distributing?*

Brief description of the event*

Who are you partnering with to distribute locks?*

Do you have another event?*

Select or enter value

V. Distribution Plan for Second Event

Distibution Plan 2

Please provide a brief outline of your plans for distribution (e.g., distribute at a special event, through specific programs in your office, as part of counseling sessions).

Event 2 Date

Event 2 Name

Link to Second Event Webpage

How many locks do you plan on distributing?

Brief description of the second event.

Who are you partnering with to distribute?

VI. Comments

Comments

Please share additional information about special orders or general comments.

Thank you for increasing firearms safety and helping IDPH work Together for a Safer Illinois. If you have additional questions, please send an email to DPH.Safety@illinois.gov.

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