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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.
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