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Coronavirus Product Donation Request Form

Company/Group Name (optional)

First Name*

Last Name*

Address Line 1* (Unfortunately we cannot ship to PO, AFO or APO addresses.)

Address Line 2

City*

State*

Zip Code*

Phone Number*

Email Address*

What Is The Name Of The Organization You Are Donating To?

Is This Donation Approved By The Above Organization?

Yes

Organization Contact Name

Organization Contact Email

Organization Contact Phone

How Many People Are Involved With This Project?

Approximately How Many Hours Of Work Per Week Will Be Committed To This?

What Items Will You Be Making? (You may select more than one.)

Masks

Gowns

Other*

*If you selected “Other”, please tell us what items you will be making.

Please Give Us Some More Details, Are You...

Donating Products

Charging Cost of Materials

Selling Products

Please List The Products You May Be Interested In From Cleaner’s Supply (Separate each with a comma.)