NMDOH Gun Violence PreventionGun Lock Request Form

NMDOH Gun Violence Prevention

Gun Lock Request Form

Please complete the fields with the full and complete corresponding information. We cannot ship gun locks outside of the state of New Mexico. All information you provide will NOT be sold or distributed to any third party vendor or listserv.

Any questions may be sent to Alexander Cutler, Gun Violence Prevention Program Coordinator, at alexander.cutler@doh.nm.gov.

Date*

Please enter today's date.

Gun Lock Request

Please complete the fields with the full and complete corresponding information below.

Is this request for yourself or for an agency or organization?*

ie: are you ordering the lock for yourself, as an individual? Or is this request for a bulk order on behalf of an organization?

Select

Mailing Address*

City*

State*

Select

Zip Code*

Name of Clinic/Agency/Organization*

Clinic/Agency/Organization Mailing Address*

Clinic/Agency/Organization City*

Clinic/Agency/Organization State*

Select

Clinic/Agency/Organization Zip Code*

County*

If more than one, include all.

Select

Number of Gun locks Requested*

Communities Served

For example, pediatrics, family medicine, tribal populations, seniors, general public.

Person Submitting Request:

First and Last Name of Person Submitting Request*

Title*

Phone*

Email*

Send me a copy of my responses

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