Face Mask Request Form

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This form is for businesses and organizations (primarily in Bartholomew & Brown county) to request HOMEMADE FACE MASKS from our community of volunteers who are ready, willing, and able to supply you with the masks you need! Complete this request, and your facility will be contacted within 24 hours to verify specific mask guidelines/requirements. Thank you!

Facility Name: *

Facility Location: *

Please list street address/city.

Facility Contact Name: *

Facility Contact Phone #: *

How many masks does your facility need? *

i.e. 30-Adult, 10-Pediatric

Specifications:

If you have a link to published specs for a specific type of mask, please provide it here. Thank you!

Additional Comments:

Submit

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