PPE REQUEST
If your nursing homes, front line workers, food service workers, health care workers, police departments, fire departments, or childcare workers NEED masks, gloves, or hand sanitizer PLEASE FILL OUT THIS FORM. We will be in touch as soon as possible. We will try to fulfill as many requests as we're able.
Facility Name
Type of facility:
Nursing Home
Senior Living
Hospital
Urgent Care
Pediatrician
Primary Care
Dental
Childcare
Fire Department
Police Department
Food Service
Type of PPE needed:
KN95 equivalent masks
Latex Gloves (S)
Latex Gloves (M)
Latex Gloves (L)
Non-Latex Gloves (S)
Non-Latex Gloves (M)
Non-Latex Gloves (L)
Hand Sanitizer (8 ounce bottle)
Number of above PPE needed:
Facility Shipping Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Facility Contact Name
First Name
Last Name
Facility Contact Title:
Facility Contact Email
example@example.com
Facility Phone Number
-
Area Code
Phone Number
Please list any questions or important info about your facility/location:
Submit
Should be Empty:
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