Surgical Mask Distribution Form
The Town of Pantego has acquired surgical masks from Tarrant County. While these masks aren't the N95 masks, they still do offer a layer of protection. We will distribute these as quickly as possible to residents and businesses who need them. While we may not be able to fully meet every need, masks will be distributed as equally and as fairly as possible until supply is depleted.
****all information gathered as part of this process will be kept confidential and shared only with essential members of the Town****
Name of Person Filling Out This Form
Phone Number Person Filling Out This Form
Is this for residents or business?
NAME of Family / Business Needing Masks
Primary PHONE Number
ADDRESS of Family / Business Needing Masks
Is any member of this residence considered high risk for COIVD19?
Yes. One or more of the following: respiratory history, elderly, immunocompromised
What is the IDEAL NUMBER OF SURGICAL MASKS we can provide you?
We have the ability to deliver your masks. Do you need delivery?
I can pick them up
I need them delivered
What other COVID-19 needs we can help your family or business with? Shopping assistance, etc. (please include detail)
Send me a copy of my responses.
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