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Resource Request Form for Goods & Services
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* Indicates required question
Are you a health care facility, agency or non-profit organization providing health care, food, shelter, and other essential services throughout the duration of the COVID-19 pandemic?
*
Yes
No, this is a request for an individual or family needing assistance due to self-quarantine or self-isoloation
Name of Business, Agency, Organization
Skip this question if submitting an individual or family request
Your answer
Primary Contact Person (First & Last Name)
*
Your answer
Please provide a detailed and complete description of the item(s) you need assistance with procuring. Be sure you indicate quantities, sizes, date needed, etc.
*
Your answer
Email Address
*
Your answer
Phone Number
*
Your answer
Alternate Phone Number
Your answer
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