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COVID-19 PPE & Disinfectant Request Form

2. COVID-19 PPE & Disinfectant Request Form
   Please complete this form in its entirety. We reserve the right to substitute products based on current stock and shelf life.

   Please complete this form in its entirety. We reserve the right to substitute products based on current stock and shelf life.

4. Date*
   Date

   Please enter the date.

5. Department, Office, or Municipality*

   Enter the department, office, or municipality this request is for.

7. First Name

8. Last Name

10. Phone Number*

    Requester Phone Number

11. Requestor Email*

    Enter your email address.

13. Address1

15. City

16. State

17. Zip

19. Products

21. Select Item

    1. Hand Sanitizer 8oz.

22. Qty

23. Select Item

    1. Disinfectant Spray (Case of 12- 24oz.-32oz. bottles.)

24. Qty

26. 1. Hand Sanitizer 1 Gal. Case

    (Case of 4- 1 gallon containers. Contains 1 pump.)

27. Qty

28. 1. Disinfectant Wipes

    *This product is in short supply and may be substituted for spray.

29. Qty (Number of packs)

31. 1. Face Masks

32. Qty (Box of 50)

33. 1. Reusable (Cloth) Masks

34. Qty (Packs of 50)

36. 1. Face Shields

37. Qty

41. Gloves
    -- Select One --VinylNitrile

    Select Glove Type

43. Small

    Enter Quantity (Boxes)

44. Medium

    Enter Quantity (Boxes)

45. Large

    Enter Quantity (Boxes)

46. Extra Large

    Enter Quantity (Boxes)

48. Gloves
    -- Select One --VinylNitrile

    Select Glove Type

50. Small

    Enter Quantity (Boxes)

51. Medium

    Enter Quantity (Boxes)

52. Large

    Enter Quantity (Boxes)

53. Extra Large

    Enter Quantity (Boxes)

57. Comments

    Please provide additional information here.

Leave This Blank:


59. 1. Receive an email copy of this form.
60. Email address

    This field is not part of the form submission.

61. Submit

* indicates a required field