Request Form

Maine Residents: Use this form to request a complimentary BD Safe-Clip™ needle clipping device courtesy of the Maine Department of Environmental Protection, Becton, Dickinson and Company, and Rite Aid Pharmacy.

If you have questions, please contact Michael Parker, Maine DEP Biomedical Waste Program, (207) 287-7704.

Labels followed by * are required fields.

Name *

Address 1 *

Address 2

City *

State/Province or N/A * Not Applicable Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Flordia Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory

Zip Code *

Phone in this format
207-123-4567

Email Address