Business/Organization Support Signup Form

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If you'd like to participate in our mask drive program, as a business, nonprofit, or other organization, please fill out the information below and we'll follow up with you to address your needs. This program is first-come, first-served and based on the donations we are provided. There is no guarantee you will receive materials. We will; however, do what we can to address your issues and concerns. Thank you for your patience and participation as we, as a community, get through this difficult time. If you have any questions or would like to volunteer to support the effort, please contact Jeff Eggleston via email at ejeff@warren-county.net or call 814-584-2203.

Email *

Your Name

Organization

Organization Address

Phone Number *

Email Address *

What items do you need help acquiring? (check all that apply)

Masks for my staff

Masks for my customers/clients

Hand Sanitizer

Cleaning supplies to sanitize

Safety apparel (other than masks) for my workers

Other:

Mask Need Estimate (this does not need to be exact but a best guess)

1-25

26-50

52-100

101-250

250-500

500+ (Larger Organization)

Clear selection

General Question or Comments

A copy of your responses will be emailed to the address you provided.

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