MDWARN: Reusable Cloth Masks Request Form
Please complete all sections of this form to request reusable cloth masks for full time employees (FTE) of a Maryland Water or Wastewater Utility. Please note that the Point of Distribution (POD) location is 8270 Old Montgomery Rd. Columbia, MD 21045. Note: We highly recommend that you only choose delivery to your address if you have a FedEx or UPS shipper account on file.
Requesting Utility Name: *
Requesting Utility Type (i.e. Water or Wastewater): *
Approximate number of population served by utility: *
Preferred Method of Delivery *
Billing Address for Delivery Fee (if Delivery is your chosen method). If choosing pick-up, enter N/A. *
UPS or FedEx Shipper Account Number (if delivery is chosen). If choosing pick-up, enter N/A: *
Additional special instructions for delivery, if applicable. If choosing pick-up, enter N/A: *
Requesting Utility PWSID/NPDES Permit Number: *
Utility Address (Street, City, State, Zip Code): *
Utility County: *
Utility Point of Contact (POC) Name (First and Last): *
Utility POC Phone Number: *
Utility POC Email Address: *
Number of Full Time Employees (FTE): *
Total Amount of Reusable Cloth Masks Requested (2 Masks/FTE): *
Requestor Name (First and Last): *
Requestor Phone Number: *
Requestor Email Address: *
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