Health4TheWorld COVID-19 PPE Drive: Donors/Sellers/PPE or Mask movements
Thank you for your willingness to participate in the H4TW C0VID-19 PPE Drive! We are so grateful for your kindness during this extremely challenging time. Please fill out the brief form below to help us deliver your donation as efficiently as possible.
Sign in to Google to save your progress. Learn more
What is your name? *
What is your email address? *
What is your cell phone number?
What company do you represent? *
What is your company's street address? *
What is your company's state? *
What is your company's website?
What is your company's ZIP code? *
What is your company's country? *
How would you characterize yourself? *
Are you hoping to donate the supplies or sell at a reasonable price? *
What supplies are you able to donate or sell at a reasonable price? In the relevant spaces below, please mention the quantity available for each item and the cost per piece. If an item is a donation, please enter '0'. If you do not have an item available, please leave blank. For example, if you are donating 100 items, please list '100; 0'. *
Required
Nitrile gloves
Vinyl gloves
Medical grade N95 masks
Non-medical grade N95 masks
Surgical or procedure masks
Cloth masks
Safety goggles
Face shields
Protective gowns
Hair-covering bonnets
Shoe coverings
Bleach or disinfecting wipes
Hand sanitizers (CDC approved)
Other
Can you deliver the supplies directly to a local hospital? *
If you can deliver supplies directly to a local hospital, what mile radius are you willing to drive?
Can you ship the supplies nationally? *
Can you ship the supplies internationally? *
If so, to which countries can you ship?
Please provide any additional details that might help us best utilize your kind donation!
Heath4TheWorld, Inc. is a California non-profit public benefit corporation.  As a charitable organization, our mission is to foster public health and access to healthcare education in under-resourced parts of the world.  We provide our services on a charitable basis and therefore make no claims, representations or warranties, whether express or implied, as to the safety, reliability, durability, performance, merchantability and/or fitness for any specific purpose of any products sold or donated by third-parties.  Health4TheWorld accepts no liability whatsoever for the safety, reliability, durability, performance, merchantability and/or fitness for any specific purpose of any such products. *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Health4TheWorld. Report Abuse
Google Forms