Resource Request Form for Goods & Services
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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
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