CLSA + California OES PPE Request Form for California Life Sciences
Governor Newsom’s Office of Emergency Services has asked for our help.

While their supplies last, they have offered to provide a free supply of PPE (masks and hand sanitizer) to essential industries in California to help restart the economy until the supply of PPE can catch up to demand.

Through our partnership, we have agreed to receive and distribute the PPE supplies to key life sciences companies in California. For larger orders (more than 2,000 masks) we can have them ship directly to you, but will need to provide them with your information.

Please note that hand sanitizer will come in gallon bottles and masks have a minimum order of 2,000. If you need less than a count of 2,000 masks, CLSA will be able to order for you and bundle smaller amounts for pickup at or delivery from our South San Francisco and San Diego office locations.

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First and Last Name of Requester *
Email address of Requester  (do not use personal email addresses) *
Company Name *
Briefly describe your company *
How many employees does your company have? *
Provide the shipping/mailing STREET that the PPE supplies will be delivered to (this needs to be a business address). *
Provide the shipping/mailing CITY that the PPE supplies will be delivered to (this needs to be a business address). *
Provide the shipping/mailing STATE that the PPE supplies will be delivered to (this needs to be a business address). *
Provide the shipping/mailing ZIP CODE that the PPE supplies will be delivered to (this needs to be a business address). *
Provide the shipping contact (First and Last Name) if different than Requester. *
Provide the shipping contact's email address *
Provide the shipping contact's phone number with area code *
MHE (Material Handling Equipment) on site? *
Are you a CLSA Member? *
Is there any other COVID-19 related support that CLSA can provide at this time? Provide details below. Enter "N/A" if you do not need support. *
What challenges do you foresee as the economy re-opens? *
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