Resource Request Form for Goods & Services
Are you a health care facility, agency or non-profit organization providing health care, food, shelter, and other essential services throughout the duration of the COVID-19 pandemic? *
Name of Business, Agency, Organization
Skip this question if submitting an individual or family request
Primary Contact Person (First & Last Name) *
Please provide a detailed and complete description of the item(s) you need assistance with procuring. Be sure you indicate quantities, sizes, date needed, etc. *
Email Address *
Phone Number *
Alternate Phone Number
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy