Corporation Questionnaire 2

MaskGrant PPE Quote Form

Your purchase helps frontline healthcare workers access the PPE, supplies, and services they need most. Thank you for your generous gift!

What is your name?

What is your email address?

What is your phone number?

What is the company name?

What is your company website URL?

What is your company address?

What type of masks are needed? How many? (Medical, N95, KN95, Surgical)

What other supplies are needed? How many? (Surgical Gloves, Isolation Gowns, Protective Goggles, Coveralls, Face Shields?)

Do you have an institution or hospital you want to support?

No, any on the list is fine

Yes

What's the name institution/hospital?

What's the website institution/hospital?

Thank You. Your information has been submitted!