PPE Request Form - California Grocers Association

Medical Mask Request Form

Please complete the form below to register your request to receive PPE products. You will receive an email confirming receipt of your inquiry and a status on your request in the coming days. Note that order requests are for store-level staff and shall not exceed a 30-day supply of each product. If you have any questions, please email Doug Scholz, CGA, at [email protected].

Company Name*
Name*
First Last
Email*
Mobile Phone*
Number of store-level employees*
Please provide number of items requested below. Items should be for use by store level employees. Number of each item requested shall not exceed a 30-day supply.
3-Ply Surgical Masks KN95 Respirators Hand Sanitizer Bottles (16.9 oz)
Delivery contact name*
First Last
Delivery contact email*
Delivery contact mobile phone*
Delivery location street address*
Delivery location city*
Delivery location state*
Delivery location zip*
Delivery notes
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.