Supplier Intake Form

I Have Supplies to Donate

Company / Organization and Contact Information

Contact Name

Title

Phone Number

Alt Phone Number

Company Name

Please ensure this is the complete company name, including Inc., LLC, etc.

Company Tax ID Number (U.S. Entities Only)

Company Address

City

State

Postal Code

Hours of Operation

I have a contract with the City of Los Angeles.

Contract Number

Product Supply Information

Identify the quantities you can donate that meet the CDPH specifications (PDF).

Resource

Quantity

N95 Masks

N95 Masks Quantity

Surgical Masks

Surgical Masks Quantity

Isolation Gowns

Isolation Gowns Quantity

Nitrile Exam Gloves

Nitrile Exam Gloves Quantity

Latex Exam Gloves

Latex Exam Gloves Quantity

Other Medical Grade Items

Other Medical Grade Items Quantity

Other Supplies

Product Information

Model Number

Manufacturer

EPA Registration Number

For disinfectants and other chemical products, including hand sanitizer.

FDA/NIOSH/CDC Approval Number

For masks and other PPE.

Supporting Documentation

FDA/EPA/CDC/NIOSH documents, price sheets, product specifications, product images.

Maximum 10 files.
10 MB limit.
Allowed types: pdf jpg png.

Choose files

Location / Delivery Information

What is your current available inventory?

Where is your inventory located?

What is your manufacturing lead time?

What is your shipment lead time for delivery to the City of Los Angeles once order is placed?

What are your payment terms?

Please indicate if this is either a payment or donation.

Do you accept purchase orders?

Yes

Additional Information

Math question 6 + 7 =

Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.