County of Los Angeles Covid-19-related Donations Form

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* 1. Contact Information

Contact Name

Company Name

Telephone Number

Email Address

Website Address

Address

City

State

Zip

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* 2. Type of Donation (Select at least one)

Food

Transportation

Supplies

Storage/Facilities

Pick Up/Delivery Service

Volunteer(s)

PPE/Healthcare Equipment

Lodging

Communications/Media

Other (list below)

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* 3. Please describe the donation, including capacity:

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* 4. Can you transport the donation, if applicable?

Yes

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* 5. If the donation is offered in a language other than English, please list the language(s).

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* 6. Is the donation being offered for a cost?

Yes

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* 7. Please provide any details related to the cost of the donation, if applicable.

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* 8. Is the donation worth more than $10,000?

Yes

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* 9. What is the earliest date that you could provide the donation?

Date / Time

Date

Time

AM/PM

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* 10. Please briefly describe your company/organization.

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* 11. Do you/your organization have experience providing disaster relief?

Yes

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* 12. Do you currently do business with Los Angeles County?

Yes

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* 13. If yes, please describe.

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* 14. Please provide your Los Angeles County Vendor Number, if applicable.

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* 15. Please provide any additional information regarding the donation that was not included above.

Thank you for your willingness to assist during this uncertain time. Someone will be in contact with you soon.