PPE Request Form - ShieldOurHeroes.com
We will do our best to provide PPEs per your request. Our supplies are limited and prioritized for healthcare so please explore other avenues as well. To make a PPE request, please provide the following information (AVAILABLE ONLY IN PARTS OF: CA, IL & NY).
Your Organization's name *
Organization's street address (delivery ONLY to commercial address) *
Department name
City *
State (LIMITED TO ONLY CA, IL & NY): *
Zip code *
Contact's full name *
Contact email address *
Contact Mobile Number *
Contact's role/title *
Face Shield (homemade, wipe down before use)
If urgently needing face shields, how many do you anticipate using in the next 7 days? 
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Cloth Mask (homemade, wash before use)
If urgently needing cloth masks, how many do you anticipate using in the next 7 days?
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Gown (plastic, homemade, not sterilized)
If urgently needing gowns, how many do you anticipate using in the next 7 days?
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OUT OF STOCK - N95 - factory made (mostly in China, brands may vary)
If urgently needing factory-made N95 masks, how many do you anticipate using in the next 7 days?
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OUT OF STOCK - KN95 - factory made (mostly in China, brands may vary)
If we are out of N95s and you can use KN95 masks instead, how many do you anticipate needing in the next 7 days?
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Urgency of this request *
Additional note (comments, other PPE needs, delivery instructions, etc)
Submit
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